The many measuring methods of humeral head retrotorsion angle using CT were reported. The purpose of this study was to compare the methods which were reported in the past with our original method. Pneumo-arthro CTs of two hundred of one hundred patients with unilateral posttraumatic recurrent dislocation of the shoulder were examined. Eighty-seven patients were male and thirteen were female. We measured the retrotorsion angle using CTs at the levels of the humeral head and the distal humerus. We adopted three kinds of lines at the level of the proximal humerus: the S line (Simeonides' Method), the L line (Laumann's Method) and the A line our original method. We also adopted two lines at the level of the distal humerus: the T line (Tosu's Method) and the R line (Randelli's Method). We measured the humeral retrotorsion angle using a combination of the proximal three lines and the distal two lines. We also examined the reproducibility of three proximal methods by multiple measurements and the measurement by multiple testers. The retroversion angle using a combinationof the S line and the T line was 29.6±12.1°(-5.5 to 59.4°), and using acombination of the S line and the R line was 27.0±129°(-72 to 63.3°). The results using a combination of the L line and T or R line were 29.3±22.3°(-292 to 84.3°) and 27.0±22.1°(-24.5 to 76.2°). The results using a combination of the A line and the T or R line were 30.4±10.9°(6.2 to 57.5°) and 28.3±11.2°(2.1 to 57.0°). The different of the mean value of the retrotorsion angle were not significant by any kinds of measuring method atthe level of the humeral head. However, the standard deviations of results using the L line method were extremely bigger than those using the S and A lines. The L line method showed an extremely high and low angle compared with the other two methods, and seemed to be less reproductive. Our original method using the A line was the most easily reproducible. The mean value of the retrotorsion angles were approximate whichever method was used at the level of humeral head, but the standard deviation of the result by using the L line method was extremely bigger than those using the S and A lines. Our method using the A line was most easily reproducible compared with the methods using the S and L lines.

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The purpose of this study was to analyze the scapular movement and the scapulo-humeral rhythm inthe rotator cuff tear. The condition of the rotator cuff in the second joint was also evaluated. There are few previous reports concerning these kinematics three dimensionally using an open MRI system. The subjects consisted of 15 rotator cuff tear patients and normal volunteers, respectively. The subjects were fixed to an open MRI and inclined with free motion around the scapula. MRI images were taken at the accurate scapular plane at every 30°arm-trunk angle from 30°in the supine position. Images in the coronal, transverse and sagittal planes and the 3D volume images were also taken. The scapular angles (the upward rotation angle, the medially tilting angle, the scapular downward tilting angle) were measured. The cuff condition in the second joint and the distance between the humeral head and the undersurface of the acromion (3DAHI)were measured on the 3D analyzing software. The upward rotation angle tended to increase in theearly phase, and the medially tilting angle was not relatively constant in the rotator cuff tear patients compared with normal volunteers. The scapular downward tilting angle changed from anterior to posterior with elevation in the normal volunteers, but it did not change posteriorly in the cuff tear patients. There was a tendency for them to be narrowes in the second joint concerning those with the kinematics condition of the rotator cuff in both groups. The 3D-AHI had asmaller value in the cuff tear group, especially when it was at the minimum 90 degrees abduction position. A subacromial narrowing in the second joint is likely to happen during abduction in both groups. One of the reasons of a bad scaplo-humeral rhythm in the rotator cuff tear is due to a poor scapulo-thoracic movement.

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The purpose of this study was to examine the biological reaction and deterioration for rotator cuff reconstruction by a PTFE felt graft under polarized and dispersed light with an animal model Eight adult beagle dogs were used. After making a defect of infraspinatus tendon, a piece of PTFE felt was overlapped on the torn tendon, and was drawn into the cancellous bone trough. The defect of the infraspinatus tendon was 1 cm. At three, six, nine, twelve, twenty-four and fifity-two postoperative weeks, the bone PTFE interface (; BPI) and tendon PTFE interface (; TPI) were evaluated microscopically. At three and six weeks, fibroblasts and loose connective tissue had entered between the PTFE fibers in the BPI and TPI, and the collagen fibers were increased as time passed. At nine-twelve postoperative weeks, there were many debris of PTFE and macrophase in the marginal portion of the bone trough. The dense connective tissue was aligned parallel to the collagen fibers of the infraspinatus tendon fibers in the TPI and perpendicular to the trabeculae in the BPI. At fifty-two postoperative week, there was deterioration of PTFE fibers in thealigned collagen fibers in the TPI and at the bottom of BPI, and this phenomenon was progressive as time passed. In the process of the histological healing of a PTFE felt graft, debris of PTFE felt in the early time point in the margin of BPI, the reason seemed to be mechanical stress was stronger than the other portion. Once the PTFE felt acquired enough adaptation to the tissue, but deterioration of PTFE fibers later on will concern the enlargement of a bone trough in the clinical cases.

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The JOA shoulder score has been widely used for the evaluation of the function of the shoulder. However, no studies have been published yet concerning its interobserver reproducibility. In this study, we attempted to clarify this point. Fifty shoulders of forty-six patients (average age, fifty-two), who were newly admitted to the shoulder clinic in the Tohoku University Hospital, were assessed by 3 orthopaedic doctors on the same day. The JOA score was evaluated independently using the manual for Evaluations of the Shoulder. Pearson's correlation coefficient (r²) was calculated between each observer for the total score. As for the scores of each criterion including pain, function, active daily life (ADL), range of motion (ROM), radiologic finding and stability, Spearman's rank correlation coefficient was calculated. In the total score, the r² value between each observer was more than 0.78. It seemed that the total score strongly correlated between each observer. In the analysis for each criterion, the ρ-value between each observer was high enough in function, ADL and ROM Especially, the score for ADL showed the highest ρ-value (0.88-O.93). Hewever, the scores for pain, radiologic findings and stability represented the lower ρ-value than those for other categories. The total score of the JOA shoulder score represented satisfactory interobserver reproducibility. To obtatin better interobserver reproducibility in each criterion, one has to double-check the manual during the assessment of patients.

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The purpose of this study was to evaluate the hardness of the shoulder girdle muscles objectively from the body surface.
Eighteen healthy adults were examined as standard (the healthy group). The comparative objects were nine adults who complained of stiffness of the trapezius (the stiffness group) and seventeen painful shoulders (the case group).
The measuring muscles were biceps brachii, pectraris major, triceps brachii, trapezius upper fiber, rhomboid, and back extensor. We measured 3 times from the body surface using a PEK-1 (Imoto's product) that measures muscle flexibility. From these data, we compared the hardness in other parts on the basis of the muscle hardness of biceps and triceps. Furthermore, we compared them with each group.
Hardness of the biceps and triceps has quite a high correlation with other parts only in the healthy group. By comparing other parts on the basis of the biceps and triceps, each group showed different patterns.

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We evaluated the postoperative results for rotator cuff tears. There were 74 patients (76 shoulders) who underwent surgical repairs of the rotator cuff tears in 1991-1999 that could be followed-up for 1 year postoperatively. They were 40-77 years old (mean 61.2 years old) and consisted of 52 males and 24 females. The numbers of shoulders were 9 in incomplete,46 in complete (other than massive ones), and 21 in massive tears. They were operated on by McLaughlin's method or a fascial patch procedure. Preoperative and postoperative evaluations were made according to the JOA score. The mean of the JOA score improved from 70.2 to 94 in incomplete, from 65.7 to 93 in complete, and from 59.8 to 91.7 in massive. The postoperative improvement rate of pain scores were the highest in all groups. Our results of operative treatment for rotator cuff tears were satisfactory.

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The purpose of this study was to determine the diagnostic performance of MR arthro- and bursography for incomplete rotator cuff tears.
Seven shoulders in seven cases of surgically proved incomplete rotator cuff tears from 1999 to 2002 were studied. There were six males and one female with an average age of fifty-three point nine years old. There were four right shoulders and three left. After an injection of amidotrizoate sodium meglumine into the glenohumeral joint and subacromial bursa, MR images were obtained preoperatively.
A comparative study between the findings of preoperative MR arthro- and bursography and the surgical findings was performed.
All shoulders were distinguished from complete rotator cuff tears. Three shoulders were bursal side tears, two shoulders were intratendinous tears and two shoulders were articular side tears. MR arthro- and bursography revealed adequate diagnosis in bursal side tears. However it revealed inadequate diagnosis in intratendinous tears and articular side tears.
MR arthro- and bursography was a reliable method for incomplete rotator cuff tears. However it was not helpful to diagnose intratendinous tears and articular side tears.

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We evaluated rotator cuff tears (RCT) with the reconstructed coronal and sagital view after arthrographic helical computed tomography (arthro-HCT) in order to improve the diagnosis. Our cases consisted of fifteen patients, eleven men and four women, with a mean age of forty four point eight years. Their diagnoses were as follows: eight RCT, four recurrent dislocation, one long head of biceps tear, one frozen shoulder, and one after rotator cuff repair. In this study, we evaluated the size and position of RCT with arthro-HCT. In all cases using arthroscopic examination, we performed a comparative study in order to determine which method led to a more precise diagnosis, MRI or arthro-HCT. Arthro-HCT nearly showed the exact condition of the RCT in the eight RCT cases. In two cases, no RCT was found, but the following bursographic HCT showed a bursal-side partial tear. In the other five cases, there were no RCT in the capsuler sides. In all cases using an arthroscopic examination, only arthro-HCT showed the accurate size and position ofthe partial or small RCT. MRI failed to reveal the exact RCT because of the surrounding inflammation, concluded that an arthro-HCT is the most useful examination to evaluate the size and position of RCT.

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A rupture of the rotator cuff tendon may induce muscular fatty degeneration, which can be observed with computed tomography (CT) imaging. The purpose of this study was to examine the frequency of fatty degeneration in patients with a complete rotator cuff tear using CT images.
Twenty shoulders in twenty eight patients (average age sixty point seven years old ) with a complete cuff tear were studied. Fatty degeneration was evaluated using CT images and assessed by Goutallier's classification. The diagnosis of rotator cuff tear was made by the examiner, after which the frequency of fatty degeneration was determined. Supraspinatus tendon ruptures were found in eleven patients, infraspinatus tendon ruptures in two, supraspinatus and infraspinatus tendon ruptures in six, supraspinatus and subscapularis tendon ruptures in eight, and all three tendons were found ruptured in three. The frequency of fatty degeneration in the infraspinatus tendon was 66.7%, while that in the supraspinatus and subscapularis tendons was 35.7% and 23.1%, respectively. Some reports have concluded that postoperative results for rotator cuff repair are inferior when fatty degeneration has occurred, thus, it is best if surgery can be performed prior to its appearance. From the results of the present study, we considered that fatty degeneration is more prevalent with the infraspinatus tendon. Therefore, when a rupture of the this tendon is suspected, an operation should be carried out as soon as possible.

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Four patients with fractures of the osteoporotic surgical neck fracture were treated by internal fixation with an intramedullary locked nail(Polarus nail). Two cases were re-operations. Two patients were male and two were female. Their mean age was eighty-three point five years old( range, seventy-seven-eighty-nine years old). The follow-up period averaged six months. All fractures healed. The Postoperative ROM of re-operated two patients were poor, but the others were good. All the patients had no severe affected shoulder pain and returned to ADL. The Results of functional outcome according to the JOA score were as follows. Median postoperative JOA score was 75.5 point (pain23.7, function 16.3, range of motion 20.3, joint adaptation 4.5, joint instability 13.8) Various methods have been used for osteoporotic proximal humeral fractures. But poor bone stock in the elderly limit the use of them. An intramedullary device with a facility for locking allowed control of rotation and prevent proximal migration. Polarus nail was intramedullary locked, hollow, unreamed made of Titanium alloy. Its tapered tip reduced the distal stress concentration. It was provided with with a radiolucent targeting device to facilitate insertion of both proximal and distal locking screws. There were 5 screw holes for proximal locking. These were directed in anteroposterior, lateral, and oblique directions to maximize fracture fragment fixation.
Osteosynthesis of osteoporotic surgical neck fracture using Polarus intramedurally rod was a useful procedure.

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We reported on three cases of post-traumatic osteolysis of the distal clavicle (ODC). All the cases had a direct injury to their shoulders and common clinical courses.
Case 1: A seventeen year-old male. A university student (judo player). He hit his left shoulder on the floor forcibly during judo, and then he had pain in his left shoulder. When he visited the clinic at first, there were no abnormal findings in the roentgenograms of his shoulder. Then he had conservative treatment but he did not stop practicing judo. We found ODC in his roentgenograms four months after he was injured.
Case 2: A thirty-four year-old male. A contractor. He hit his left shoulder on the road surface forcibly in a motorbike accident. After which he had left shoulder pain. There were no abnormal findings in the first roentgenogram of his shoulder. He had conservative treatment, but he did not stop work. We found an ODC in his roentgenograms two point five months after his injury.
Case 3: A fifty-nine year-old male. A painter. He hit his right shoulder on the body of a car forcibly in a motorbike accident. After that, he had right shoulder pain. He had subluxation of the right acromioclavicular joint in his first roentgenograms. He trained his right shoulder as best he could, although he had had conservative treatment. We found ODC in his roentgenograms six months after his injury. We performed resection of distal clavicle in all cases. There were granulationlike tissues in the osteolytic area near the acromioclavicular joint in all cases. No articular disc was found. We found microscopically osteolysis and stoppage of bone trabecula in their specimens. There were no specific changes in their osteolytic areas. ODC is a comparatively rare disease. Various theories have been proposed about the cause - aseptic necrosis, synovial proliferation, microtrauma and so on. However we do not know the true cause of ODC. In our examinations, we suggested the possibility that post-traumatic ODC arise from microtrauma for repeated minor trauma to the clavicular end after a minor injury.

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The purpose of this report was to detect the incidence of shoulder joint injuries, we prospectively performed arthroscopic studies at the time of the removal of the internal fixation devices(BEST acromioclavicular plate) in ten patients with distal clavicle fractures. About three months after the operation we removed the BEST plate and performed arthroscopic examinations. Ten patients with distal clavicle fractures were treated with a BEST plate. There were eight males and two females. The average age at the time of surgery was thirty-seven point one years old, with a range from twenty to sixty years old. Arthroscopies revealed chondral injuries of the glenoid fossa in nine patients out of ten. Six SLAP lesions were also noted. From our study we infer chondral injuries of the glenoid fossa are frequently associated with distal clavicle fractures. So we consider that osteoarthritis of the shoulder may develope in the future.

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The purpose of this study was to report our experience with surgery in the treatment of thoracic outlet syndrome(TOS). All patients who has undergone surgery for TOS and were followed-up for more than six months after surgery. There were three females and one male. The age of the patients at operation ranged from seventeen to thirtythree(average twenty six point eight). The follow-up period from six months after patients underwent surgical decompression of the transaxillary approach. Treatment consisted of a resection of the first rib, resection of the pectoralis minor muscle and neurolysis of the brachial plexus. After surgery patients reported improved pain(four/four), hand muscles strength(four/four), hand function (four/four), and sensory disturbance(three/four). Surgical complications were not recorded. Sensory disturbances were transient and did not result in permanent symptomatic sequelae. Transaxillary rib resection was a safe and effective procedure, allowing all patients all patients to return to their normal activities.

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We reported a case of pseudogout, which showed complete destruction of bilateral shoulder joints. An eighty four year-old woman suffered rt-shoulder pain and local heatness. In May,2001 she presented herself with swelling of bil-shoulders when she carried a package. CRP was 4.92, rheumatoid factor was not detected, in the examination of the joint fluid, a CPPD crystal was detected. In the bacterial cultivation of the joint fluid, bacteria was not detected and on cell examination, malignancy was not detected. She had ft-shoulder pain and swelling, so we performed an operation. Large quantities of synovia were found, which we extracted by hand. The suprasupinatus tendon had disappeared and we resected the destructive humeral head, acromion and distal end of the rt-clavicle. Sixteen months passed since the operation, there was no local recurrence. CPPD crystals were recognized from specimens under a polarizing microscope and diagnosed as pseudogout. This case was classified F type according to McCarty complete bone destruction of bil-shoulders. In this case of complete destruction, the suprasupinatus tendon disappeared, So a massive synovectomy and resection arthroplasty were performed. The results were satisfactory.

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Two types of humeral head (mono-polar and bi-polar) are available in humeral head replacement (HHR)but which type of head has advantage for treatment of rheumatoid arthritis shoulder is controversial. We experienced an RA patient, who had received a bipolar type HHR, and was suffering from prolonged shoulder pain and limitation of ROM caused by anterior subluxation of humeral head after operation. We thought a large volume of bipolar humeral head could induce posterior tightness and cause anterior subluxation, and performed revision surgery on the patient using a small bio-modular humeral head (mono polar head) to loosen the posterior soft tissue. After the revision surgery, pain was releived and a good ROM was achieved. Bi-polar humeral head had the advantage gaining two motion surfaces in the gleno humeral joint and could diminish a destruction of glenoid bone. But, large volume of bi-polar head could induce soft tissue tightness. The operative findings of soft tissue tightness using trial head could give us important information to decide the type and size of humeral head at the time of HHR

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We reported on five cases of intratendinous horizontal tear of the rotator cuff ( IHRCT: supraspinatus tendon). There were five men, whose mean age at surgery was thirty-one. Common findings of the physical examination: were no tenderness at the greater tuberosity; positive impingement sign; no glenohumeral contracture. MRI( T2: FSE) showed a liner high intensity area in the supraspinatus tendon, T2^*(GRE) showed a higher intensity, and less signal changes around the higher intensity area A wavy appearance of the tendon was seen by bursoscopy. After making a trial incision at the lateral aspect of the rotator cuff insertion, the torn site of the cuff was cleaned using a shaver, and tenorrhaphy with a suture anchor were performed. The mean follow-up period after surgery was nineteen months (6-32 months). The mean JOA shoulder score improved to 94points (73.7 points before surgery; p=.01: Paired t-test). The combination of MRI (T2/T2^*) and bursoscopic evaluation was useful for the diagnosis of IHRCT. High-intensity of the mid-layer even in T2might be a definitively positive sign of IHRCT, and which showed less degenerative findings in T2^* a good indication for arthroscopic repair.

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We reported on a case which had a dislocation of the tendon of the long head of biceps (LHB) associated with isolated tear of the subscapularis tendon, and who underwent an open reduction of the LHB. In September 2001, a fortyfour-year-old-ma injured his right shoulder taking his child running in his arms. His right shoulder was forced into extension, and he had sharp pain in the front of his shoulder. Motion pain and night pain continued for a month. In October 2001, he visited our hospital. On physical examination, there were a tenderness on the lesser tuberosity and pain with a click on the bicipital groove during the Yergason test's maneuver. Active shoulder movement was not limited. Roentgenograms showed no abnormal findings. CTA and MRI showed a medial displacement of the LHB from the bicipital groove, and they showed no findings of the rotator cuff tear. In November 2001, an operation was performed. The subscapular tendon was partially torn horizontally and the LHB was dislocated inside the subscapular tendon. A reducition of the LHB and a repair of the subscapular tendon were performed. Nine months after the operation, MRIs showed effusion of the subacromial bursa, there was pain and swelling on the bicipital groove.

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The purpose of this study was to analyze the motion of the acromioclavicular joint (ACJ) after the fixation by Wolter clavicular plate. In this study, two groups were evaluated. One was the fixation group, which were diagnosed as grade III ACJ dislocation according to Tossy's classification (five cases, mean age thirty-four years old) and treated by a modified Neviaser's procedure using Wolter clavicular plate as a temporary fixater. The other was a control group, which were diagnosed as rotator cuff tear (three cases, mean age sixty point seven years old) treated with an open rotator cuff repair.
The movements of the acrornion relative to the distal clavicle were measured and expressed as changes in angle on the sagittal plane (SA) and horizontal plane (HA) at 45°and 120°flexion or 45°and 120°abduction In the control group , the mean values of SA and HA at 120°flexion were 16.7°and 15.0°and SA and HA at 120°abduction were 15.3°and.3°and 6.7°, respectively. In the fixation group, SA and HA at 120° flexion were 7.2° and 6.2° and SA and HA at 120°abduction were 5.6° and 5.2° indicadng a decrease in motion of the ACJ compared with the control group. This study indicated that a fixation by Wolter clavicular plate restricted the motion of the acromioclavicular joint.

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Percutaneous Kirschner wire fixation for early exercises in dislocations of the acromioclavicular joint were carried out. A 3mm Kirschner wire was passed percutaneously under the acromion and into the clavicle after closed reduction in six patients. The arm was elevated after the arm was supported in a sling for two weeks. The wires were removed at seven-eight weeks after the surgery. In four patients, subluxation of the acromioclavicular joint was found after a pin removal. Normal acromio-clavicular articulation was maintained in only two patients. There was no breakage of Kirschner wire as well as osteoarthritis of the acromio-clavicular joint A wire migration occurred in a seventy-eight-year old patient. Percutaneous Kirschner wire fixation passed under the acromion into the clavicle in an acromioclaVicular dislocation was easy to perform and useful, but we do not recommend this method for older patients with osteoporosis.

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We evaluated the surgical results of fresh complete acromioclavicular (AC) dislocations utilizing the Tetron tapeR for reinforcing coracoclavicular (CC) ligaments. Thirty-one patients with complete AC dislocations were treated from 1996 to 2000. All the cases were males, and the mean age was thirty-two years old (fourteen - fiftyeight). There were thirteen right and eighteen left shoulders. They were followed-up for an average of fifty months (twenty-five - seventy-seven) postoperatively and evaluated with JSS-ACj score, full marks of which were 100points. We also examined the radiographic changes around AC joints. The average postoperative JSS-ACj score was 95.1±6.2 points(73-100). The radidgraphic evaluations revealed ossifications of the CC ligament(eleven cases). bone hypertrophies of the distal end of clavicle (two cases) and osteoarthritic change of the AC joint (four cases). Bone erosions of the clavicle or the coracoid process by a synthetic material was not evident A displacement within 50% of the AC joint height was observed in twenty-five cases (Group I), while its was over 50% in the remaining six cases (Group II). There were no postoperative complete dislocation. JSS-ACj score of Group I and Group II was 96.6±4.3 points and 88.8±9.5 points, respectively. There was a significant difilerence between the two groups (p<0.01). But no other radiographic changes had a relationship to the clinical results. Overall, the clinical results of this procedure were satisfactory, though a mild degree of subluxations was present in 19% of the patients.

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The purpose of this study was to report the surgical results of a distal clavicle resection. Eight patients (six male, two female) underwent surgical treatment Their mean age was thirty-seven years old. The current disease contained 4osteoarthroses,2 acromio-clavicular separations, a fracture of the distal end, and a post-traumatic osteolysis. The mean follow-up period was seven months. Pain, muscle strength, and range of motion were, assessed using the modified JOA shoulder scoring system. The impingement phenomenon, instability of the gleno-humeral joint and a complication were evaluated. The modified JOA score postoperatively deteriorated in two female patients. The outcomes of the JOA scores became better in six patients. Their gleno-humeral joints were not clinically unstable in any of the patient. Two of eight patients had numbness, a cold sensation and pain of the upper extremity on the surgical side. The upper extremity was bony connected to the trunk only via the acromio-clavicular joint. In cases with the distal clavicle resection, the scapulothracic joint was only stabilized by surrounding muscles and coraco-clavicular ligament Among patients with muscle insufficiency around the scapula, thoracic outlet syndrome might occurr postoperatively.

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The purpose of this study was to review the results of surgical treatment with modified Neviaser's method for a grade 3 dislocation of the acromioclavicular joint. In our modified Neviaser's method, a bone fragment at the attachment of the coraco-acromiaryok ligament was fixed to the clavicle by a K-wire which was inserted to the hold the acromioclavicular joint. This study involved fourteen patients (thirteen males and one female) with a mean age at surgery of thirty years old. The duration from injury to operation was ten days on average and that of follow- up was ten months on average. The clinical results were evaluated by Kawabe's score and the Japan shoulder society(JSS) score for an acromio-clavicular dislocation. Postoperative evaluation was 95 points( excellent tweleve, good two ) in Kawabe's score, and 96 points in the JSS score (excluding the X-ray points). There were the cases which had a shoulder pain. There were six patients who had mild subluxation in X-ray postoperatively. The ranges of motion of the shoulder was full in all cases, but the calcification of the coraco-clavicular ligament was observed in twe patients. Our modified method showed satisfactory clinical results, and the rigid fixation of the coraco-acromiar ligament could make it possible to start range of motion active exercise immediatety after surgery.

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The purpose of this study was to compare clinical results of surgical treatment and conservative treatment for acromio-clavi-cular dislocation with a Type V according to Rockwood's classification.
Fifteen patients were diagnosed as Type V acromio-clavicular dislocation. Con-servative treatment was performed in six patients, and surgical treatment in nine. The mean age at the time of injury was forty-eight point eight years-old in conservative treatment group, and thirty-nine point nine years-old in surgical treatment group. A mean follow-up period was twenty-seven point eight months in conservative treatment group, and seven-teen point three months in surgical tre-atment group. In conservative treatment, the range of motion exercises were initiated after fixation of the sling for a short term. In the surgical treatment, after the reposition and internal fixation according to Bosworth's method, the coraco-clavicular ligament was sutured in three patients. After Kirschner's wire fixation of the acromio-clavicular joint, the coraco-clavicular ligament was re-constructed by the transfer of the coraco-acromial ligament in six patients. The clinical evaluations were done acc-ording to the JOA scores. The average JOA score was 69.9 points in conservative treatment group and 91.2 points in surgical treatment group. The average scores of pain were 21.7 points in conservative treatment group and 28.3 points in surgical treatment group. The average scores of function were 19.3 points in conservative treatment group and 19.6 points in surgical treatment group. The average scores of ROM were 27 points in conservative treatment group and 28.1 points in surgical treatment group. Total JOA and pain score were statistically significant difference between conser-vative treatment group and surgical trea-tment group. The results of operative treatment for acromio-clavicular dislocation with Rockwood's type V were sat-isfactory in evaluative pain compared with conservative treatment, but clinical re-sults needed a longer follow-up.

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The purpose of this study was to evaluate the short-term results of modified anterior capsulolabral reconstruction (ACLR) for recurrent anterior dislocation of the shoulder. Ten patients who had recurrent anterior dislocations of the shoulder were treated with ACLR. The mean age was twenty-three point five years old. The operative procedure consisted of transverse splitting of the subscapularis, the horizontal capsulotomy, capsulolabral repair with suture anchors and overlapping of the capsule. Active and passive ROM exercises within 90° of abduction and flexion,45° of external rotation started on postoperative day one, but an arm sling was worn for about three weeks except during physical therapy. The goal for full range of motion was eight weeks, and the goal for return to sports games was six months. The mean duration of follow-up was one point eight years. The patients were evaluated with the Rowe score, ROM, apprehension sign and internal rotation strength. All patients had no recurrence of dislocations and apprehension sign, and had a score of 100 points on the Rowe score. The mean limitation of external rotation was 2.8 degrees, and the mean internal rotation strength was 99.1% of the healthy side. Standard open procedures such as the Bankart procedure and inferior capsular shift have been proven successful in providing stability but not sufficient ROM and muscle strength. Although the arthroscopic procedure yielded better results in terms of ROM and strength, the resultant stability seemed to be inconsistent. On the other hand, ACLR restored not only stability but also good results for ROM of external rotation and strength of internal rotation in our cases. This is probably because of the horizontal capsulotomy which prevents overtightening of the capsule, and splitting of the subscapularis which is less invasive for the muscle.

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We evaluated the diagnostic value of the stress view in the shoulder joints. We performed the stress view in shoulder joints using a Telos shoulder positioning device from 2000 to 2002. There were eighteen patients and thirty-six shoulders. The positioning of the anterior stress view was abduction at 90 degrees and external rotation at 60 degrees, and the posterior one was abduction at 90 degrees and neutral rotation. A fifteen kg stress was obtained in both anterior and posterior views. The position of the center of the humeral head was evaluated in the glenoid from the it's anterior edge. We divided it into three groups: group A (recurrent anterior shoulder dislocation) six cases, group B (multidirectional instability of the shoulder) four cases and group C (throwing shoulder) eight cases. The mean of anterior stress in group A was 33.3% on the operated side and 50.8% on the other side. It was a significant difference. The posterior ones in each were 54.2% and 56.9%. The mean of anterior stress in group B was 34.7% on the operated side and 43.1% on the other. The posterior ones in each were 71.1%and 70.6%. In group C they were 47.6% on the injured side and 53.3% on the other. The posterior ones in each were 50.9% and 58.8%. There was a significant difference. This stress view in shoulder joints had a diagnostic value.

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For athletes of non-contact sports, we have been performing the arthroscopic Bankart procedure using TwinFix anchors since 1998. Here, we report the therapeutic results of this surgery. The subjects were nineteen patients consisting of eighteen males and one female. The age at the time of surgery ranged from eighteen to forty-two years old (mean: 27.8). Types of sport were: baseball in five cases (all were infield players); golf in three; skiing in two; volleyball in two; tennis in two; soccer in two; and others in three. Eight of the nineteen patients were at a competition level. In preoperative physical examination, anterior apprehension test and relocation test were observed in all patients, but no patients had multidirectional instability. On radiographic findings, the Bankart lesions were observed in all the patients but a small bony Bankart lesion was obtained in five patients. Regardless of the condition of instability, the residual glenoid labrum was properly detached from the scapula neck in all the patients and the arthroscopic Bankart procedure was performed using TwinFix anchors. The number of these anchors was determined based on the area of the detached glenoid labrum. The follow-up period was between two years and four years and five months (mean: two years and ten months) and the therapeutic results were evaluated according to the JOA score and JSS shoulder instability score. No patient developed a dislocation or subluxation after surgery. None of the anchors was pulled out or broken. In the postoperative range of motion, the external rotation was restricted by about 6.3 degrees on average compared to the non-affected side. Return to the original sport was permitted six months after surgery. All the patients could return to their original sport at the level before the injury one year after surgery. Excellent results were obtained without recurrent instability by the arthroscopic Bankart procedure using TwinFix anchors in athletes of non-contact sport.

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Since 1997, we have performed the arthroscopic Bankart repair procedure on traumatic anterior instability of the shoulder joints of athletes. The purpose of this study was to evaluate the operative results. Fifty-eight shoulders of fifty-eight cases (thirty-seven males and twenty-one females) with traumatic anterior instability have treated with arthroscopic Bankart repair procedure (Caspari's procedure (TG group) and suture anchor procedure (SA group)). The average age at the operation was twenty-three years old. TG group had thirty-five cases and the SA group had twenty-three cases The clinical evaluations were performed using the JSS Shoulder Instability Score. Using 3DCT images, we investigated the shape of the glenoid. We evaluated the muscle strength of the inner muscles using Cybex. As to the clinical results, the TG group showed an improvement from 41.6 points to 83.4 points and the SA group showed an improvement from 47.2 points to 91.0 points. The limitation of external rotation in the arm at side position was -7.7 degrees in the TG group and -3.5 degree in the SA group. Using 3DCT images, we found the bony defect at the Bankart lesion in 91 % of the cases. The SA group had better results than the TG group. In 63.6% of all cases, we found a bony defect at the injured site compared with the healthy site using the 3DCTs. When the bony defect was bigger, the limitation of external rotation increased. The recovery to resume sports activities was better more than 6 months after operation considering the results of our muscle strength measurement.3DCT images were very useful to detect the bony Bankart lesion.

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We sought to evaluate our current method of surgical treatment of the recurrent anterior dislocation and subluxation in JSDF personnel. Twenty-three shoulders in twenty-one personnel were evaluated. All were males with an average age of twenty four point seven years old (range nineteen to thirty-three) at the time of surgery. The average time of follow-up was four years and one month (range two to six years and four months). The evaluations of clinical results were by: 1. Rowe' s shoulder score,2. Range of motion,3. Re-dislocation ratio,4. Satisfaction rating,5. Return to pre-morbid activities,6. Complications.
Twenty-two of twenty-three shoulders had good to excellent results when rated by the Rowe's scoring method. Redislocation ratio was 0 %, re-subluxation ratio was 4%. The average range of motion was diminished to seven degrees when compared to the normal unaffected side. Almost all of the twenty-one patients were satisfied with the treatment. Four failed to return to their pre-injury activities because two feared a re-dislocation and two were not in their pre-injury circumstances. The physical demands of the JSDF pesonnel are strenuous and demanding. JSDF personnel with dislocated shoulder require careful and precise repair to stabilize the shoulder to return as soon as possible to the force and as many as their pre-injury activities. The symptoms of recurrent dislocation or subluxation were enough to keep some individuals from returning to their full pre-injury functions. Confidence and stability are the keys to successful repair and return. If these findings are not there, JSDF personnel must be directed into less strenuous activities.

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The purposes of this study were to investigate the non and delayed union of diaphyseal fractures of the clavicle and to identify the risk factors associated with such problems. Two hundred three diaphyseal fractures of the clavicle were treated at our clinic from August 1987 to August 2000. Type2A fractures of Robinson's classification were forty-three and type2B were one hundred sixty. We treated all fractures conservatively till August 1990, but most fractures with complete displacement surgically since September 1990. The patients and treatment factors for nonunion and delayed union were analyzed statistically. All patients of type2A fractures with bony contact healed uneventfully. Two patients of type2B fractures without bony contact developed nonunion and five delayed union which was defined as healing more than five months. Two patients of nonunion were treated conservatively. One patient was thirty-nine years old and male.
Another patient was fifty-seven years old, female and suffered from chronic hepatitis. Both fractures were displaced more than 20 mm after reduction. Two of five patients with a delayed union were treated surgically. One was fortyseven years old, male with a re-refracture and the other was sixteen years old, male with a refracture. The other three patients with a delayed union were treated conservatively and displaced more than 20 mm. In addition, their ages were fifty years or more. Most studies concerning the risk factors for nonunion focused on displacement In this study, displacements more than 20 mm were associated with poor prognosis of union the same as in our former studies. Furthermore age and refracture were considered as risk factors of a delayed union.

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We showed the classification of the complex injury patterns of the shoulder girdle and reported on the clinical results of the treatment for the severe complex injury including a three or four site injury. We classified the shoulder girdle injuries into 4 sites as follows: (1) Injury around the acromio-clavicular ligament (2) Injury around the coraco-clavicular ligament (3) A scapular neck fracture (4) A mid-clavicular fracture. Complex injuries were classified with a combination of these. The patients with a three or four site injury, consisted of five men and two women with a mean age of fifty-nine point seven years old (sixteen to seventy-eight). The patterns of injuries were as follows: four cases of (1)+(2)+(4), one case of (1)+(2)+(3), two cases of (1)+(2)+(3)+(4). We performed surgically in two injury sites in four cases, and one injury site in two cases. We did conservative management in one case. In one case with conservative management, there remained a clavicular nonunion without few complaints. In one case with one injury-site fixation, there remained a nonunion of both the acromion and the coracoid process with motion pain. In cases of significantly displaced three or four site injury of the shoulder girdle, it was difficult to get the tight fixation with conservative managements: So we needed surgical reconstructions of at least two injury sites. In case of needing to reconstruct, we recommend to try reduction and fixation of each fracture because ligament reconstruction is difficult.

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At present, there is no way to evaluate gleno-humeral joint using a motion analyzer. We examined the measurement of the movement of the gleno-humeral joint from the body markers and went on the movement analysis of the throwing shoulder. The body markers of the scapula were set at 5 places. The differences were examined in 3 different elevated positions combined with 4 different directions. The relation between the angle of the glenoid fossa and the minimally different points were measured in the horizontal plane and the scapular plane. The angle of the glenoid fossa in X-ray films was compared with the estimated angle from the body markers. Finally, the ball release points of the throwing were examined in cases with SLAP lesion. The minimum difference between bony landmarks and the markers in each position were the coracoid process and acromion. The dispersion in these 2 points of 95% confidence intervals was within the range under 4. At the ball release, the gleno-humeral joint was horizontally extended in cases with a SLAP lesion. It became possible that the movement of glenoid fossa was analyzed by choosing the acromion and coracoid process as landmarks of the scapula.

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The purpose was to investigate the efficacy of several diagnostic methods to detect superior labrum injuries in throwing shoulder. Fifty-four throwing athletes, who underwent arthroscopic surgery, were prospectively studied. There were superior labrum injuries in twenty-four cases and loose attachment of the superior labrum in six. The efficacy of preoperative diagnostic methods were investigated comparing them with arthroscopic findings of superior labrum injuries. The forced shoulder abduction and elbow flexion test (forced abduction test) was diagnosed as positive, when pain at the postero-superior aspect of the shoulder in forced maximal abduction was reduced or diminished in elbow flexion. The most useful test to detect superior labrum injuries was the forced abduction test, and the sensitivity, specificity, and accuracy was 73%,69%, and 70%, respectively. Loose attachment of the superior labrum significantly increased false positive rate of this method. Forced abduction tests were simple and effective for diagnosis of superior labrum injuries in throwing shoulders.

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Sp braces were made of plastic plaster for athletes who had suffered from shoulder and elbow problems when throwing. Its shape was spiral and its function was to keep the arm in the scapular plane. The purpose of this paper was to examine the efficacy of this SP brace. Thirty-nine college baseball athletes were checked for pain, tenderness, strength at a preseason medical checkup. Then they wore an SP brace and were asked about the suitability of the SP brace at throwing, They were divided two groups, A and B. Group A did not their throwing disturbed, however group B had their throwing disturbed when wearing an SP brace. The checkup data were examined statistically and compared. A group had nineteen patients. Four athletes had shoulder problems and three had shoulder and elbow problems. B group had twenty. Six athletes had shoulder problems and nine had shoulder and elbow problems. There was a statistical difference between groups A and B. Many factors participate in throwing injuries. Skill was one of the most important factors. If the arm was kept in the scapular plane or at the zero position during acceleration phase, the mechanical stress at the shoulder and elbow joint was reduced. This SP brace was effective to keep the arm in the scapular plane and educate the throwing mechanics.

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Purpose: The side side tear of the rotator cuff and the tear of the posterior superior labrum of throwing athletes are common arthroscopic findings. The purpose of this study was to evaluate the results of arthroscopic surgery in nine cases with both injuries and to clarify the mechanism of both injuries. Material and Methods: Nine cases, which were operated from July to December,1999 were evaluated. The mean age of the cases was twenty years. Under arthroscopy, with the arm placed in external rotation and over 90-degree abduction, posterior superior glenoid impingement was found between the labral tear and joint side tear of the rotator cuff. The mean follow-up period was twenty-six point three months. The postoperative results were evaluated by JOA score and sports score. Results: The average JOA score increased from 71,2 points to 93,2 points. The average JOA sports score increased from 22,8 points to 80,2 points. All of nine cases returned to baseball. Five cases were satisfied with the results. Conclusion: An arthroscopic debridement for both injuries was effective. We believe that the articular side tear of the rotator cuff and posterosuperior labral tear occur as a result of posterior superior glenoid impingement in overhead throwing athletes.

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We studied pathogenesis for a throwing shoulder evaluating the findings of arthrogram, MR-arthrogram and arthoscopy and studied the validity of the treatment evaluating the Shoulder Sports Score and Recovery rate. Twenty-four baseball players were studied. Insufficiency of SGHL with SLAP lesion induces anterior instability of the shoulder during throwing. We chose procedure SLAP repair for SLAP lesion, and debridement for a partial thickness joint side tear of rotator cuff. SLAP repair and debridement of rotator cuffs were done for on fourteen players. Debridement were done on six players Eighteen players could play baseball completely and recovered to the level before injury and six players could not. Players could recover completely got 96(85-100) points of the Shoulder Sports Score and players who could not recover got 61(35-95) points. Twelve players who had SLAP repair and debridement of rotator cuffs could recover. Only Two players who had debridement of the rotator cuffs could recover by insufficiency of SGHL. Twelve players can continue to play baseball for three years after their operations.

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We reported on fifty clinical features of peripheral nerve palsy in the shoulder region of which causes such as injury and ganglion could not be identified. We examined fifty patients with peripheral nerve palsy due to unknown causes from 1985 to 2001. We clarified the focus that caused paralysis, on the basis of detailed clinical symptoms and electro-physiological tests, and examined the clinical courses. Forty cases had a preceded acute pain (twenty cases had an antecedent or trigger). The diseased nerves were fifteen suprascapular nerves, nine long thoracic nerves, three axillary nerves, and nineteen cases were in more than one nerve. Most cases including the operated ones showed improvement of muscle atrophy. Seven cases that showed ES at the beginning perfectly recovered. Four cases had not improved at the point of after three years and more of onset. Among fourteen cases which could be traced the process by MRI, four cases retained a high intensity of T2, even electro-physiological test showed normal findings. Eighty percent of the fifty cases were considered as neuralgic amyotrophy reported by Parsonage & Turner in 1948, given the characteristic process. The rest-20 % indicated various clinical features, which suggested more than one pathema.

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We assessed the influence of the humeral head offset on the clinical outcome of total shoulder arthroplasty (TSA) and humeral head replacement (HHR) for patients with rheumatoid arthritis (RA). The clinical results of TSA (six shoulders)and HHR (four shoulders) of ten RA patients followed up for more than one year were examined and the relation between the outcome and the increase of humeral head offset after TSA and HHR were analyzed. The clinical results were evaluated with JOA shoulder rating system (JOA score). The shoulders were classified into two groups by increase of offset after TSA and HHR. The six shoulders with the same offsets showed better muscle strength, ADL activity, active flexion and passive flexion compared with the other shoulders with an increased offset The increase of the humeral offset after TSA and HHR for RA patients induced soft tissue tightness, and provided a poor clinical outcome.

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Septic arthritis of the shoulder is uncommon in adults. We reported on the cases of four patients. Between 1991and 2001, a total of eighteen patients with joint infection in general were admitted to our hospital. Of these, four patients had septic arthritis of the shoulder. There were two males and two females aged from sixty-five to eighty-six years old (means seventy-two). Two patients had predisposing factors. One patient had had steroid injections of the shoulder before development of the infection. Three patients had infected different organisms. Each one had only a pseudomonus aerginosa, a citrobacter koseri, or a staphylococcus aureus. In one patient, the organism was not isolated. Two patients were not successfully treated by only an operative drainage, so they were treated by arthrotomy, debridement, and insertion of a drain. One patient was treated by arthroscopic debridement and insertion of a drain. One patient was treated by arthrotomy, debridement, decapitation and insertion of drain. After treatment, three patients regained forward flexion 90 degrees or more, one patient with decapitation had no active motion of the glenohumeral joint.

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The aim of this study was to evaluate the short term results of arthroscopic release for a stiff shoulder. Thirteen shoulders of twelve patients who underwent arthroscopic release for the stiff shoulder were studied. There were seven males and five females. The average age at operation was fifty-one point three years old (range: twenty-two-sixty-eight years old). There were frozen shoulders in six shoulders, a posttraumatic contracture in one shoulder, postoperative contractures in two shoulders, and contracture with rotator cuff tears in four shoulders. The mean duration of follow-up was twenty-four months (twelve-sixty months). The postoperative results were evaluated as JOA score, range of motion, visual analog pain scale (VAS), and satisfaction with the operation. The average JOA score improved from 57.2 points preoperatively to 85.5 points one year after operation. The average flexion was 94°preoperatively,15°intraoperatively and152°one year after the operation. The average external rotation was 16°,58°, and 49°respectively. VAS of night pain and motion pain improved.11 patients were satisfied with the surgery. Arthroscopic release for a stiff shoulder might be an effective procedure.

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