The aim of this study was to investigate the mechanical properties of the regeneration of a rotator cuff using non-woven chitin fabric (NWCF) as biodegradable scaffolds. The bilateral infraspinatus tendons and their insertions from 5 Japanese white rabbits were removed to create the defects (10x10mm). The defects were closed with a NWCF, which was inserted into the bony trough (chitin group). The contra lateral defects were not treated as a control (the control group). The shoulders were removed at 12 weeks after surgery. The mechanical properties of each specimens were evaluated using a material testing machine. A statistical comparison was performed using Student's t-test. The significant level was set at 0.05. There were no significant differences of the ultimate load to failure and tensile strength between the chitin group (135.6N,10.5MPa) and the control group (126.1N,8.4MPa). Stiffness and tangent modulus in the chitin group (47N/mm and 0.48MPa) was significantly higher than that in the control group (31N/mm and 0.4MPa). The tendon-bone insertion failed in the chitin group (n=4) and in the control group (n=3). The mechanical properties of the chitin group were a stronger than that of the control group. The NWCF as acellular matrix may have stronger regenerated tissues. However, further development of a suitable scaffold for rotator cuff engineering should be clarified.
The Purpose of this study was to analyze the articular contact pattern of the normal glenohumeral joint. There are few previous papers concerning the dynamic contact patterns, although the studies of using the cadaver or the tracking device have been reported. The subjects consisted of 10 normal volunteers. The subjects were fixed on a tilted stand with free motion around the scapula.3D MRI images were extracted at the scapular plane at every 30° between 30° and 150° in the supine position. The images obtained at each position were transmitted to a personal computer and the description of the bony frame by digitizing methods using the analyzing software were developed. Three dimensional reconstruction of the glenohumeral joint were performed. The items of measurement were the following (1)The contact area; the distances between the humeral head and the glenoid surface were calculated and the distribution set at the distances were considered to be the contact area. The shortest distance was regarded as the proximity of the joint. The change of the center of the distribution was investigated. (2)The center of the humeral head (3) Kinematics of the humerus; (from the aspect of the scapula) Results: (1)In the contact area; the minimum contact area had shifted superiorly up to 90 or 120° elevation, but after 120° it shifted inferiorly. Concerning the antero-posterior direction of the glenoid, it shifted antero-inferiorly at the elevated position compared to that of the 30Thlevation. (2)In the center of the humeral head; it shifted superiorly at 120° or 150° compaired to the 30° elevation. Its change was within 3mm. (3)In the Kinematics of the humerus; although the glenohumeral movement was totally 66°, it was only 17' after 90° elevation. We conclude that although the contact area shifted superior until 90°, it shifted to the central part of the glenoid over 120°, because the centripetal force might have worked at the elevated position. The distribution of the contact area was assumed to be reflected as a result of seeking a good congruity of the humeral head and the glenoid.
The purpose of this study was to compare the humeral retroversion measured using a CT with the direct measurement. We analyzed twenty-nine dry cadavers (fifty-eight humeri). Fifteen were male and fourteen were female. We adopted two measuring methods using the CT to draw the humeral head axis; Simeonides'Method (Method S) and our original method (Method A). The retroversion angle using Method S was 33.8 ±8.6° (15.6 to 53.8° ), and using Method A was 31.7 ± 9.5° (4.6 to 52.8° ). The result of the direct measurement was 31.9 ± 9.0° (8.5∼ 56.3° ). There was no significant difference of the mean value of the retroversion between the result of the measurement using CT and the direct measurement. The difference of the humeral retroversion between Method S and A (Method A minus Method S) was 2.1 ± 4.0° (0.2∼12.3° ). Forty-three cases (74%) were within ± 5°. We also analyzed a series of three CT slices of the five cases where had the differences of retroversion between Method S and A was extremely big or small. The absolute value of the difference between slice 1 and slice 3 was 1.6 ± 0.6° (1.3∼2.8° ) in the cases where the differences of retroversion between Method S and A were small, and 4.9 ± 2.9° (0.2∼7.7° ) in the cases that the differences of retroversion between Method S and A were big. There was a significant difference in these two groups. We hypothesized that the axis of the ellipse of the base of humeral head inclines against the axis of the humeral shaft in a few cases.
Throwing shoulder has subclinical joint laxity, but quantitative evaluation of laxity is very difficult and has not been established yet. We designed a new “shoulder positioning device” and attempted to evaluate the joint laxity of the throwing shoulder using of this device. Bilateral shoulders of 14patients with a throwing shoulder were evaluated in this study. The average age was 21.5 years old. The subjects were seated in the device. Both scapulas were fixed on the back, and the shoulder was positioned in 90 degrees abduction with 90 degrees external rotation. A stress radiogram was filmed under a 5 kg of load on the proximal site of the humerous toward anterior and antero -inferior, and the amount of the humeral head against the glenoid were measured. We found a significant difference between the dominant and nondominant shoulder joint in the amount of the antero-inferior humeral translation. The most significant difference was found in the direction of the anteroinferior at 60 degrees. The force given to the shoulder from the cocking phase to the acceleration phase of throwing directs toward antero-inferior, and the repetitive stress placed on the anterior capsular structure of the glenohumeral joint. Our device made the position of the arm similar to the real throwing position, and could take pictures of 2 directions. Therefore it was possible to measure the direction of the joint laxity of the throwing movement. As a result the direction of the joint laxity at the antero-inferior 60 degrees was confilm.
The purpose of this study was to evaluate to relationship between the humeral head and the glenoid in the elevation position, to judge the instability of the glenohumeral joint.251 radiographs of patients under thirty years old at the elevation position without contracture were examined (Group C). Further,50 radiographs of preoperative patients with instability of glenohumeral joint without trauma were examined (Group LS). At the supine position, The radiographs were taken in the elevation position and were intended to hold at the zero position. The NIH image software was performed to analyze the relationship between the humeral head and the glenoid. Three points were determined: the superior edge of the glenoid (A), the inferior edge of the glenoid (B), and the center of humeral head (C). The following measurements were evaluated; 1) SCE (shoulder center edge) angle was defined by the line BC and the perpendicular line (L) from AB to C.2) SH (scapula humerus)angle constituted of the axis of the spine of the scapula and humeral axis. In group LS, the SCE angles were significantly small and the SH angles were significantly large. In patients with over 190 degrees of SH angle, the SCE angles were significantly small. In group LS, the SH angle was above 190 degrees. We define the shouldr center edge angle and the scapla humerous angle. Many patients who had instability of glenohumeral joint could not hold zero-position. We defined the instability of the grenohumeral joint in the elevation position on radiographs as the SCE angle below 35 degree, and the boundary area as the SCE angle within 35 to 40 degrees.
Partial-thickness tears of the rotator cuff were found exclusively in the tendon of the supraspinatus. Articular side partial tears were more common than bursal side partial tears. Most clinicians agreed that tears involving more than 50% of the thickness influence the surgeon to perform a repair. However, there has been no report demonstrating the thickness of supraspinatus insertion to the greater tuberosity in Japanese. The purpose of this study was to determine the thickness of the supraspinatus insertion to the greater tuberosity in MRI of shoulder joints. There were 32 subjects (mean age; 51 years old, range; 18-82 years old). The mean distance of the supraspinatus insertion at the 10 mm lateral to the bicipital groove was 9.5 ± 1.6 mm; there was no significant difference between male and female or right side and left. Articular side partial supraspinatus tear with more than 5 mm of exposed bone lateral to the articular cartilage edge was considered involving 50% of the tendon substance.
We investigated the condition of arthroscopically repaired ligaments using MR image in abduction and external rotation position (ABER image). This study examined 17 shoulders of 17 patients with traumatic anterior instability with at least 6 months follow-up using ABER images. There were 14 males and 3 females, and their ages ranged from 16 to 49 years old (mean: 27 years old). Bankart repair was performed using 2 or 3PANALOKT' anchors with the suture-relay technique. According to the ABER images, each shoulder divided into two types; type I with a clear low signal band image of AIGHL, and type II without that. Out of the 14 preoperative type I shoulders,8 and 3 were type II at 3 and 6 months after surgery respectively. All 9 shoulders, of which MRIs were available at one year after surgery, were type I including a case which was type II at six post-operative months. All 3 pre-operative type II shoulders were still type II at 3 post-operative months, but 2 shoulders were type I at 6 post-operative months. Most arthroscopically repaired AIGHLs need 6 months or longer to become wide and thick enough to prevent an anterior dislocation.
CT-osteoabsorptiometry gave us the information about the distribution of mineralization of subchondral bone plate (DMSB). DMSB reflected the stress distribution of joint surface. We analyzed the stress distribution of glenoid cavities in throwing injures of the shoulder by CT-osteoabsorptiometry. Twenty eight patients with throwing injuries of the shoulder,24 patients with other shoulder disorders, and 4 healthy volunteers without any shoulder disorders were evaluated in this study. Group T included 28 affected shoulders of patients with throwing injuries of the shoulder. Group C included 60 non-affected shoulders of all subjects. Three dimensionally reconstructed computed tomograms (3D-CT) and DMSB of the glenoid cavities were filmed before the series of treatment. The glenoid cavity was divided into 7 areas; anterior-superior, anterior, anteriorinferior, posterior-inferior, posterior, posterior-superior and center area. The value of each area was classified into 4 grades. In group C, the mean value of the anterior-superior areas was significantly higher than those of the other areas. Meanwhile in group T, the highest mean value was that of the anterior-superior area. However, the mean values of anterior, posterior, and posterior-inferior areas were significantly higher than those of group C. The form of glenoid cavity in group T evaluated by 3D-CT showed the posterior and posterior-inferior enlargement of the glenoid cavity, which could be interpreted as a Bennett's lesion. Our results supported the hypothesis that a Bennett's lesion would be a reactive bone growth against stress onto the glenoid cavity.
Functional improvement of the shoulder joint was limited in previously reported procedures for Sprengers deformity. We performed a new procedure on three cases that includes a partial scapular resection, a removal of the omovertebral bone and a partial muscle transfer of the trapezius to improve scapula abduction. The results of these three cases are presented this method was used on 1 male and 2 female patient (age range.3 to 4 years old). On the day following the operation, passive motion exercises for the patient were encouraged. On average, flexion improved from 97 to 163 degrees and abduction improved from 103 to 167 degrees. An unsightly surgical scar had not developed. This procedure was enabled us to obtain improvement of the range of motion of the shoulder. However, long-term follow up will be necessary to evaluate the cosmetics of the shoulder
Injuries to the anterior inferior glenohumeral ligament (AIGHL) and anterior labrum, and osseous lesions, play an important pathology in traumatic anterior shoulder instability. We have performed various examinations preoperatively, and determined whether such injuries can be diagnosed. The patients consisted of 27 men and 7 women. Preoperative examinations involved arthrography, CT arthrography (CTA), MR arthrography (MRA), and 3DCT. Intra-articular lesions were evaluated: the site of the detachment of the anterior labrum; the presence of Hill-Sachs lesions; the presence and size of Bankart lesions; the presence of osseous Bankart lesions; and visualization of AIGHL. From the CTAs, the articular capsule adhered to the anterior margin of the glenoid in only 3 cases. A Hill-Sachs lesion was present in 27 cases. Bankart lesions were detected in all cases, and they extended over 2-5 hours. Osseous Bankart lesions were detected in 15 cases. An oblique-sagittal MRA revealed the articular labrum in all cases, but AIGHL in only 19 cases. All patients had a Bankart lesion, and especially, patients with a widely detachment of the anterior labrum and AIGHL not clearly detected by MRA had instability that was due to recurrence of the dislocation.
The purpose of this study was to report the results of surgical treatment for recurrent anterior dislocation of the shoulder associated with a rotator cuff tear. Eight shoulders of 8 patients (4 males and 4 females) were investigated. The average age at surgery was 65.6 years old (range 50 - 84). The clinical results were evaluated by Rowe's scoring system. McLaughlin's procedure was performed on 2 shoulders. A modified Bristow's procedure was done on 2 shoulders with a global rotator cuff tear but good function. Rotator cuff in 4 shoulders with remarkable instability was repaired with McLaughlin's method and the anterior Bankart lesion was also repaired (3 cases by the modified Bristow's method and 1 case by subscapularis repair). The average Rowe's score was improved from 25.6 points to 84.4 points post-operatively. Anterior dislocation of the shoulder in elderly patients often associates with rotator cuff tear. Some of them fall into recurrent dislocation after a rotator cuff repair. In present series, McLaughlin's procedure with a modified Bristow's procedure resulted in contracture of the shoulder. Therefore it is important to consider with the indication of the rotator cuff repair for treating recurrent anterior dislocation of the shoulder associated with a rotator cuff tear.
Bristow procedure is a method of operation for anterior instability of the shoulder, that the results are comparatively stable. We reported on the clinical results of a modified Bristow procedure. There were 148shoulders of 138 patients operated between 1988 and 2003 and followed-up for more than 6 months. ( males 119, females 19, right side 58, left side 70, both sides 10). The average age at the operation was 25.2 years old (15 ∼ 84 yrs. ), the average follow-up period was 2 years and 7 months (6 months ∼ 15yrs). There were 101 patients (73%) who had participated in before operation including 66 competitive athletes (contact sports players 47, baseball players 6). There were 2 patients (2 shoulders) with a redislocation. the recurrence rate was 1.4%. In the anterior apprehension test, all the shoulders were positive before operation and at the follow-up 19shoulders (13%) were positive. Ninety-six patients (95%) returned to their sports. There were 4 patients with a screw breakage and 2 patients with screw that had moved out. Though the recurrence rate was low, the positive rate of the anterior apprehension test was 13%. There were 6 patients with screw troubles.
The purpose of this study was to evaluate the postoperative results of the posterior capsulorrhaphy for multidirectional instability of the shoulder between the humerus-based and glenoid-based T-capsular incisions. Sixteen shoulders in which posterior capsulorrhaphy was done after a humerus-based T-capsular incision (Group A), and 8 shoulders operated after a glenoid-based T-capsular incision (Group G) were studied. Physical examinations, X-p findings (static and loaded AHI), and MR imaging (5 shoulders in Group A and 3 shoulders in Group G) were analyzed (Mann-Whitney U-test and Wilcoxon signed-rank test; p<0.05). Preoperative and postoperative statuses of both groups were significantly the same as well as the JOA and JSS instability scores. Postoperative radiographs showed a posterolateral defect of the humeral head in 10 out of 16 shoulders (63%)of Group A. but in none of Group G. Anterior and posterior capsulorrhaphies were performed at the same time in 8 out of 10 shoulders with the posterolateral defect. The loaded AHI in the shoulders with a posterolateral defect was significantly shorter than that in the shoulders without the defect, which suggests a tighter capsulorrhaphy. The humeral heads with a posterolateral defect showed weaker MR signals contrary to similar or high signals in the heads without the defect. Ischemia of the humeral head, which might be due to injury of the posterior circumflex artery at the time of humerus-based T-capsular incision, could accelerate the posterolateral defect formation. Ten out of 16 shoulders (63%) of the multidirectional shoulder instability developed the posterolateral defect of the humeral head after the humerus-based T-capsular incision and posterior capsulorrhaphy. This may have been caused by circulatory disorders of the humeral head due to tight capsulorrhaphy and/or injury to the posterior circumflex artery. Conversely, the glenoid-based capsular incision and posterior capsulorrhaphy reconstructed shoulder function and stability satisfactorily without producing this posterolateral defect.
We verified the coaptaion effect of the subscapuraris muscle when the shoulder was immobilized the external rotation after initial anterior dislocation of the glenohumeral joint, and the practical use of the immobilizer to keep the shoulder in external rotation position. We evaluated twelve shoulders of the 12 patients with traumatic initial anterior dislocation of the shoulder. All of the patients were male, and the in mean age was 22.2 years old(range,17 to 30). Fast-spin-echo T2-weighted axial and sagittal magnetic resonance images were made, with the arm held at the side and positioned first in the maximum internal rotation and then in 15°external rotation within one week after the dislocation. We examined the coaptaion effect of the subscapuralis muscle comparing the images in the both positions. The patients were asked about the compliance and the discomfort of immobilization. Bankart lesions were identified in 11/12 shoulders (91.6%). The coaptaion effect was observed in 10/12shoulders (83.3%). All of the patients put on immobilizers for 3 weeks, and answered that discomfort was within the bounds of their torelance. Better coaptaion of a Bankart lesion was observed in external rotation compared with that in internal rotation. The immobilizer was of practical use.
Patients with an initial anterior dislocation of the shoulder were treated with arthroscopic Bankart repair. We focused on those patients who have a persistant shoulder apprehension after immobilization in internal rotation. We investigated the arthroscopic findings after initial anterior dislocation of the shoulder, and evaluated the results of arthroscopic Bankart repair. There were twenty patients with traumatic initial dislocation of the shoulder (14 men and 6 women, average 25.3 years old, ranging from 18 to 40 years old). The Bankart lesions were evaluated using Kurokawars classification, and the results of treatment were assessed with the JSS score. Arthroscopic findings showed the AIGHL-Labrum complex was detached from the glenoid in all cases. Type 1 in 12 shoulders, type 2n in 4 and type 3n in 4 were observed. A SLAP lesion (type 2 in 2 shoulders, type 3 in one) was identified in 3 cases. The average JSS score was 94 points postoperatively. Shoulder apprehension had disappeared in all cases and there were no recurrences. Detachment of the anterior labrum from the glenoid was thought to be the main pathologic lesion in patients with anterior dislocation of the shoulder. Arthroscopic Bankart repair was effective in reducing the shoulder apprehension and achieving an exllent recovery and return to sports activities.
There have been many reports about re-dislocation and external rotation motion loss after a modified Bristow procedure (B). We have attempted a modified Bristow procedure with a Bankart repair procedure (BB) and immobilization in the neutral position with an SH brace (SH) postoperatively instead of in internal rotation (IR). The goal of this study was to evaluate the postoperative acquirements of the range of motion of external rotation. We evaluated 15 shoulders with recurrent dislocation of the shoulders. All the 15 shoulders were divided into three groups according to their surgical procedures and postoperative immobilization. (BB-SH, BSH and B-IR) The motion of external rotation of the shoulder in 0 degree of abduction (ER I) and the motion in 90 degrees of abduction (ER II) were measured at 4,8,12 and 24 weeks postoperatively. Recovery rates (ratio: operatively treated shoulder / healthy shoulder) were evaluated. Recovery rates of ER I had gradually increased postoperatively in all three groups. The recovery rates of the B-SH group at 4 and 8 weeks were significantly higher compared to the B-IR group. Modified immobilization of the neutral position induces early acquirements of the motion of external rotation after a Bristow procedure.
The purpose of this study was to investigate the clinical characteristics of shoulders with traumatic anterior instability. In 1998, we surgically treated 55 shoulders in 55 patients with traumatic anterior instabilities of the shoulder. The subjects consisted of 40 males and 15 females with an average age of 23.5 years. We investigated the following points; 1) scoring system for joint hypermobility(Beighton),2)the applied force at the initial dislocation,3)the number of dislocations or subluxations,4)the age at the initial dislocation or subluxation,5)diagnoed as recurrent dislocation or recurrent subluxsation. Hill-Sacks lesion and Bankart lesion were evaluated using CT images. The average Beigh ton score was 3.9 points. As for the case of five or more points, the Bankart lesion and the Hill- Sacks lesion were not evident. The patients in which large force was received at the initial dislocation had a bony Bankart lesion. There were no correlations between the number of dislocations or subluxations and the Bankart lesion and Hill-Sachs lesion.
Most common pathology of recurrent anterior shoulder dislocation is Bankart lesion. However, anterior dislocation can also occur by humeral side avulsion of IGHL (HAGL lesion) or a midsubstance tear of IGHL (capsular tear). The purpose of this study was to evaluate the clinical features and surgical results of recurrent anterior shoulder dislocation with an isolated capsular tear. During the last 5 years,303 shoulder joints with traumatic anterior instability underwent surgery. Among these, the visible isolated capsular was 12 (3.9%). Gender was male in 9 and female in 3. The average age at operation was 25 years old. Twelve patients underwent 11 arthroscopic repairs and 1 an open-salvage repair. The location of the tear was classified into 3types: glenoid-side for 7 patients, mid-portion for 3, and humeral-side for 2. The average ages at the initial dislocation, of the patients of glenoid-side type(23.5 years old) or mid-portion type(24 years old) were older than those of patients with Bankart lesion. There were no Hill-Sachs lesions but very small adjacent to the bare area. Eight patients with a minimum follow-up of one year were studied. According to the JSS scoring system, the average preoperative score was 62.1 points and the postoperative score was 92.6 points. One patient had a recurrence 2 years after surgery. If there are any patients with recurrent anterior shoulder dislocation with a small Hill-Sachs lesion and their age an initial dislocation was high, they should be examined by ABER-MRI. A capsular tear should be fully recognized as one of the essential lesions in recurrent anterior shoulder dislocation. The arthroscopic examination and repair were useful for a capsular tear.
Excellent or good clinical outcomes of modified Bristow and Bankart procedure have been reported in our series of recurrent anterior dislocation of the glenohumeral joint for Japan Self Defense Force personnel. However, we experienced some cases that were not satisfied with their shoulder function to resume their military duties. We hypothesized that stronger muscle power recovery would be required for the soldiers to return to their military training. This study was designed to investigate the relationship between the surgical results of Bankart & modified Bristow procedure and shoulder rotational muscle strength. Isokinetic concentric shoulder rotational strength was evaluated in 14 patients treated with Bankart & modified Bristow procedure. They were all male Japan Self Defense Force personnel, and the average age at the surgery was 25.4 years old. The clinical grading of muscle strength was compared postoperatively with objective testing using a Biodex dynamometer, with functional assessment of physical strength testing, and with the ability of the patients to return to their military affairs. All patients could return to their military duties without a history of re-dislocation. The mean peak torque ratios at 60 deg/sec were recovered to 93% in the external rotation and 96% in the internal rotation. The postoperative functional scores were correlated with the internal rotational muscle strength (r=0.597, p<0.05). Surgical results were correlated with the isokinetic rotational muscle strength. Stronger rotational muscle power would be required for the patients treated with a Bankart & modified Bristow procedure to return to their military affairs.
A modified Bristow's procedure was good for stability, but sometimes patients complained of loss of external rotation. The purpose of this study was to evaluate the utility of a new idea of the post operative arm position of immobilization after a modified Bristow's procedure for return to overhead throwing sports activities. From 1980 to 2000,23 patients with recurrent anterior dislocation of the shoulders of overhead sports athletes had this operation.14 patients were baseball players,6 patients were volleyball players, and 3 patients were softball players. Their ages at the time of operation were 16 to 33 years old and the average follow-up period was 8.1years.5 patients were kept their shoulders fixed in a sling for 3 weeks after the operation (A-G) and 18 patients were kept with their shoulders abducted at 90 degrees and externally rotated at 90 degrees with an airplane brace from just after the operation (B-G). The results were evaluated according to the JSS shoulder sports score, the JSS shoulder instability score and the JOA score. The mean loss of external rotation at 90 degrees abduction was 3 degrees compared with the opposite side in B-G. None of all subjects had a recurrent dislocation. One subject had a delayed-union of the transferred coracoid in B-G. A complete return to overhead throwing sports activities was achieved in 16 of 18 patients in B-G. We concluded that this new idea of a post operative arm position of immobilization after a modified Bristow's procedure obtained good results for a recurrent anterior dislocation of shoulders with a good stability and a high rate of returning to overhead throwing sports activities.
Fractures of the glenoid fossa are relatively rare. Between 1990 and 2002, we treated operatively five patients with intra-articular fractures of the glenoid fossa. The average age of the patients was sixty-three years old (range, forty-six to seventy-seven). These patients were all men. The injuries were caused by a fall from a height in three patients, a bicycle accident in one, a motor-vehicle accident in the other. Other major injuries, including fractures of the ribs, a lumbar vertebral fracture, a clavicle fracture, a proximal humerus fracture, a pneumothorax, were common in these patients. According to Ideberg's classification system, one patient as type II, two patients were type III, one patient was type IV and one patient was type V. An anterior approach was used in four patients and a posterior approach, for one patient. Internal fixation was performed with a screw or plate for all the patients. The follow-up period averaged ten months. We evaluated the results by Japan Orthopaedic Association (JOA) score. Bony union was achieved in all patients. No cases involved a nerve injury or infection. The results were almost satisfactory. Open reduction and internal fixation was a useful method for intra-articular fractures of the glenoid fossa.
The purpose of this study was to evaluate the results of modular-type end-prosthesis for comminuted proximal humerus fractures. The patients were 1 male and 9 females, with an age ranging from 41 to 79, (average of 68.7years old).10 of the proximal humerus fractures patients (4 were 3-part fractures and 6 were 4-part)were treated by the authors operatively during these 10 years. The follow-up period ranged from 1 year to 8 years and 1 month(average 2 years and 8 months). The operation results were assessed with sheets of the Japan Orthopaedic Association(JOA score). The average postoperative JOA score was 80.3, range 69 to 90. The postoperated average ROM was 127.5° in elevation,35.5° in external rotation,93e in abduction. Patients had poorer operative results when they had waited for surgery for more than 2 weeks and when reduction of greater and lesser tuberosity anatomically was difficult. Sufficient anatomically reduction of the greater and lesser tubercles, and postoperative rotator-cuff exercisec, were important in attaining improved outcomes.
We assessed the influence of radiological evaluation on the clinical outcome of hemiarthroplasty for fractures of the proximal humerus. Twelve cases with humeral fracture treated by hemiarthroplasty were investigated. The cases were 1 male and 11 females, with an averaged age of 74 years old. The mean follow-up period was 50 months. The types of fracture consisted of 3-part fractures in 4 and 4-part fractures in 8. All the patients were evaluated by Japan Orthopaedic Association (JOA) score. The parameters for radiological evaluation were values of AHI, the humeral offset. The av erage postoperative JOA score was 76 points, ranged from 47 to 92 points. The clinical results were excellent in 2 cases, good in 4, fair in 4 and poor in 2. All patients had no pain. The value of AHI and humeral offset for 6 cases with fair or poor results was significantly lower than that for 6 cases with excellent or good results. There was a significant correlation between the postoperative JOA score and difference of AHI and humeral offset of bilateral shoulders. Our findings indicated that anatomical reconstruction of the greater tuberosity the same as co-lateral shoulders was important to gain satisfactory functional results of hemiarthroplasty.
Twenty patients (14 females,6 males) with fractures of the proximal humerus were treated by internal fixation with a Polarus humeral nail. The mean age was 66.3 years old (range 21 to 93 years old). Seven patients had 2parts,8 patients had 3-parts and 5 patients had 4-part fractures. They were operated on within an average of 7days after injury. The range of follow-up period was 5 to 29 months. Clinical and radiological bone union was confirmed in 18 patients. The mean score of the clinical outcome was 83 (range 44 to 100 points) evaluated according to the Japanese Orthopaedic Association. The good functional results indicate that the Polarus humeral nail was a satisfactory mechanical device for the treatment of proximal humeral fractures because it was less invasive and was a strong fixation.
The purpose of this study was to clarify the factors affecting the results of the endoprosthetic replacement for the comminuted fresh fracture of the proximal humerus. Twenty-one shoulders were investigated with follow up time 44.8 months on the average. The average at age at operation was 67 years old. There was 1 male and 20 females. The right shoulder was involved in 9 patients and left shoulder in 12patients. The dominant shoulder was involved in 8 patients. A 3 part fracture was seen in 6 shoulders and a 4 part fracture in 15shoulders. A monopolar endoprosthesis was used in 9 shoulders and a bipolar one was emplyed in 12 shoulders. Patients were evaluated by Japanese Orthopaedic Association shoulder score ( JOA score ) with reference to the age at operation, duration between fracture and surgery, type of fracture, type of endoprosthesis, utilization of bone cement at operation, and follow-up radiological findings. The range of motion at follow up were 121degrees of flexion, Li of internal rotation and 27 degree of external rotation. The average JOA score at followup was 80.1 points. Whether or not bone cement was used for the humeral stem fixation did not cause any statistically differences. The JOA score was higher in patients without complications (P=0.04), in patients with sufficient bone stock around the fin of the prosthesis (P=0.04), and in patients with humeral offset more than 25mm(P=0.03). This procedure was useful for elderrly patients without major complications if it was performed within 2 weeks of the fracture. Good bone stock around the fin of the prosthesis and a humeral offset of morethan 25mm were important factors for the good prognosis.
The postoperative range of motion (ROM) of the shoulder and clinical results in eighteen patients who had subacromial injections of the sodium hyaluronate (HA) after rotator cuff repairs (HA group) were evaluated and compaired with those of six patients without an HA injection (non-HA group). At operation the catheter was set inside the wall of the subacromial bursa. The shoulder was fixed for 1 week and HA was injected from the catheter on the operative day and 1,3,5,7 days after the operation in the HA group. Passive elevation and external rotation exercises were started at 1 week. Passive elevation and external rotation range in the HA group were significantly greater at 1 to 4 weeks and reached 141° in elevation and 39° in external rotation at 4 weeks. The active elevation range in the HA group was significantly greater than that in the non-HA group at 1 to 6 months and averaged 162° at 6 months which was 98% of the range of the contralateral side. The active external rotation range in the HA group at 1 to 6 months was greater, but nonsignificantly than that of the non-HA group and reached 62° at 6 months which was 94% of the range of the contralateral side. The active internal rotation range of the HA group showed a good recovery and reached Th10 at 6 months. Postoperative pain and the results were assessed according to the scoring system of the Japanese Orthopedic Association (JOA score). The total. JOA score in the HA group at follow-up was significantly higher than that in the non-HA group. A subacromial injection of HA at an early stage after rotator cuff repairs was effective for obtaining a good recovery of the ROM of the shoulder.
The purpose of this study was to evaluate the optimal location of the continuous epidural catheters (CEC) for rotator cuff surgery. Forty shoulders of 39 patients, whose average age was 67 years old underwent rotator cuff repair, were inserted a radiopaque cervical CEC(17G, Hakko, Nagano, Japan) preoperatively and identified their location by X-rays. The regimen of the postoperative pain control was unified,2ml/hour of 1%mepivacaine was administrated into the epidural space and additional analgesic agents were adequately prescribed according to the patients' request. The patients grouped into two, one that the tip of the catheter was located above C4(“Cranial Group”, n=26) and below C4/5(“Caudal Group”, n=14). The patient's backgrounds of the two groups were not uneven. The cranial group was significantly better (p<0.01) on the visual/verbal analog pain scale at the time of return to the ward, of applying an abduction brace, of starting physiotherapy, and few requested additional analgesic agents, whereas no differences in the duration of bracing, incidence of CRPS/RSD, postoperative contracture, active elevation angle at discharge, and the Japan Orthopaedic Association(JOA) shoulder score 1-year after surgery. There were no complications related to epidural catheters. We recommend that the tip of the epidural catheter for rotator cuff surgery should locate cranial to C4, but care must be taken with regards to the complications related to the deep detention of the catheter.
[Purpose] An association between reflex sympathetic dystrophy (RSD) and rotator cuff tear has been documented. However, the reason why RSD develops after surgery for cuff tear has not been clarified. This study investigated the characteristics and clinical results of RSD developed after rotator cuff repair.
The purpose of this study was to investigate the effectiveness of brisement procedures for preoperative shoulder stiffness associated with rotator cuff tears. Sixty-six shoulders of 66 patients were followed up over one year. There were 50 males and 16 females, aged from 37 to 75 years old (the mean 57 years old). They were followed up at 40 months on average (18- 61 months). The size of tear was a small or incomplete tear in all the cases. There were 49 small,6 bursal side,6 articular side and 5 intratendinous tears. They were repaired by tendon to bone sutures in all cases. Those cases were divided into 2 groups, Group S (34 shoulders): with the presence of shoulder stiffness which received brisement procedures prior to cuff reconstructions, Group C (32shoulders): with the absence of preoperative stiffness. The outcome was assessed with the JOA score and the transition of ranges of motion. Each parameter was statistically analyzed by paired t-test, Student's t-tset and Mann-Whitney's U-test. The postoperative shoulder functions improved significantly in both groups. The average total JOA score increased from 58.7 to 89.6 (p<0.001) in Group S and from 74.3 to 92.4 (p<0.001) in Group C. The range of abduction improved from 77.6° to 163.4° in Group S (p<0.001), while it improved from 148.0°to 173.4° in Group C (p<0.01). There was no statistical difference of the postoperative range of abduction between the two groups (p=0.06). The most significant difference between Group S and Group C was found in the range of external rotation, which improved from 28.2° to 35.3° (p=0.07) in Group S, while it decreased from 58.3 to 48.1° (p<0.01) in Group C. We conclude that the preoperative brisement procedures for shoulder stiffness associated with rotator cuff tears had satisfactory clinical outcomes.
The purpose of this study was to evaluate the effect of McLaughlin's method on Patients older than 75 years old and clarify the clinical findings of older patients and young patients less than 55 years old. Older patients were evaluated according to the JOA score, range of motion and muscle strength. Furthermore, the JOA score, range of motion and muscle strength were compared between the two groups. The JOA score of the older patients had improved significantly three months after surgery. The characteristic factor of older patients was weakness of shoulder muscle strength in the early stages after surgery. But muscle strength was recovered completely 12 months after surgery. We considered that McLaughlin's method was effective for older patients.
The purpose of this study was to evaluate the characteristics of failed repairs of the rotator cuff.135 shoulders which had primary cuff repair and MRI after operation were evaluated. The “Repaired group” was determined by T2 weighted images of MRI without high intensity in the rotator cuff, and the “Failed group” was with high intensity in the rotator cuff. The “Repaired group” was 105 shoulders and the “Failed group” was 30 shoulders. T2weighted images were obtained along the oblique coronal plane and we compaired the two groups by age, sex, history of trauma, thickness of the supraspinatus musle belly, tear size before operation, spur formation of the acromion, compliancy with rehabilitation, and overusing of the shoulder. The “Failed group” had characteristics of no traumatic episodes or thinning of the supraspinatus muscle belly. Almost all the “Failed group” had a high intensity in the rotator cuff in MRI at five weeks after operation. It became clear that failed repair of the rotaror cuff happens early after an operation, and a re-tear after a repair was rather rare. Even if primary repair is possible, having no traumatic episode, and thinning of the supraspinatus muscle belly made the possibility of a failed repair high.
We used a trapezius-splitting surgical approach when we performed an operation on the suprascapular notch. We reported on the safety and usefulness of this approach. To elucidate the safe limits for musclesplitting incisions of the trapezius muscles,5bodies (10 cadaver shoulders) were studied (2 males / 3 females, age: 54∼82, the average: 78). To evaluate the usefulness of this approach, we investigated the operative findings in 3 cases of suprascapular nerve palsy with a trapezius-splitting. The spinal accessory nerve was found to run a vertical course medial and parallel to the vertebral border of the scapula. Three to six nerve branches also ran a vertical course lying between 35% and 48% of the distance from the vertebral spinous processes to the acromion. The most lateral branch lay on average at 45% distance and never beyond 50%. In 3 cases of the trapezius-splitting surgical approach, we could get excellent exposure of the suprascapular vessels / nerve, which gave us a good view for the operation. No case had a spinal accessory nerve injury after the operation. To split the muscle in the direction of the fibers is useful for getting excellent exposure, and it made the operation easy. However, splitting of the muscle has a risk of injury to the neurovascular structures. There are a number of reports about the position of the axillary nerve in the deltoid. Comparing this to that, there have been few reports about the position of the accessory nerve in the trapezius. From this examination, we concluded that the trapezius-splitting surgical approach for decompression of the suprascapular nerve is safe and useful when it is done in the lateral 50% of the muscle.
The present study was undertaken to find out the alteration of the range of motion in the recovery process of frozen shoulders. Forty-five cases (26 males and 29 females), aged from 36 to 75 years old (54 in average), including 9 diabetic and 6 thyroid ailments (hyperthryodism), were followed-up in the outpatient clinic until patients became comfortable with their shoulders. The mean follow up period was 7 months in average (4 -19months). The range of elevation (EL), external rotation (ER), and extension (EX) were measured. Statistical analysis was made by unpaired -t test. The long follow up was made by questionnaire in 21 cases after 8 years on average on the final visits to our clinics. The initial average of the EL ER and EX of the patients without complications were 90 ± 13 (167 ± 17: healthy side),7 ± 16 (56 ± 27),29 ± 8 (72 ± 16) degrees, respectively. Those of the patients with diabetes and thyroid ailments were 102 ± 10,13 12,30 ± 6 and 96 ± 15,17 ± 18,41 ± 10, respectively. On their final visits, they moved to 132 ± 25,26 ± 20,50 ± 17 in the patients without complications,118 ± 18,19 ± 19,39 ± 14 in diabetic patients and 158 ± 32,32 ± 23,46 ± 10 in patients with thyroid ailments. The ranges of final visits were statistically lower than those of the healthy side. There were no recurrences of frozen shoulders after the final visits to the clinics though half of the diabetic cases felt mild symptoms in their shoulders. A complete recovery of range of motion of a frozen shoulder was not found even if the patients felt comfortable with their shoulders.
The cases of twelve patients (9 men and 3 women, ranging from 20 to 71 years old) with septic arthritis of the shoulder joints (except for children and TB) were evaluated about predisposing factors, infection, delay in diagnosis, blood checks, treatment and results. Joint aspirations led to a definitive diagnosis and almost all the patients were treated with the three essential principles in the management of a septic arthritis (1. adequate drainage,2. antibiotics through the veins,3. the joint must be rested in a stable position). The final roentgenographic appearance of the shoulder of the patients followed over one year after treatment showed some or severe osteoarthritis changes.
Arthroscopic capsular release is used to treat idiopathic adhesive capsulitis that is refractory to nonoperative treatment or pumping/manipulation under anesthesia. The purpose of this study was to report the outcome of arthroscopic capsular release in the management of frozen shoulder. Material and Methods: During a 3.0-year period, we managed eight patients with refractory shoulder contracture. Four patients had loss of motion after surgery of fracture at shoulder (postoperative group); one patient experienced shoulder stiffness without cause, two after calcium-deposit, and one after minor trauma (idiopathic group). There were one man and seven women. The mean age was 57.9 years (range,50-77). The mean duration of pre-operative conservative treatment was 6.6 months (range,4-9). We investigated the preoperative and three months postoperative scores of the Japanese Orthopedic Association (JOA score), and range of motion of affective shoulders to evaluate the short-term effect of arthroscopic capsular release. Results: Flexion and external rotation improved from a mean of 107.5 and 22.5degrees preoperatively to a mean of 148.8 and 42.5degrees respectively (p<0.01). The total JOA score (the maximum score,80points) improved a mean of 49.0 points preoperatively to a mean of 69.6 postoperatively (p<0.01). The pain, ADL, ROM score improved a mean of 16.3,7.4,16.9 points preoperatively to a mean of 25,9.5,25.8 points respectively after operation (p<0.05). There was no statistical difference in the mean total JOA score at three months after operation between two groups but the mean improvement rate was higher in idiopathic group (p<0.01). Discussion: The arthroscopic release was effective for improving range of motion and pain in patients with refractory shoulder stiffness, so we recommend adding this treatment for patients with frozen shoulder, particularly patients of postoperative contracture at the time of operation for removing instruments.
Vascular endothelial growth factor (VEGF) is a glycoprotein that plays an important role in neovascularization and increases vascular permeability. The present study investigated whether VEGF was also involved in the development of shoulder contracture in diabetics with rotator cuff disease. We examined 67 patients with rotator cuff disease, including 36 with complete cuff tears,20 with incomplete tears, and 11 without apparent tears (subacromial bursitis). The patients were divided into two groups according to the presence or absence of diabetes (14 type II diabetics and 53 non-diabetics). Expression of the VEGF gene in the synovium of the subacromial bursa was evaluated by using the reverse transcriptase polymerase chain reaction. The VEGF protein was localized by immunohistochemistry, and the number of vessels was assessed based on CD34immunoreactivity. The results showed that VEGF mRNA was expressed in significantly more diabetics (1 00%,14/14) than in non-diabetics (70%,37/53) (P=0.0159, Fisher's test). VEGFs 121 and 165 were expressed in significantly more diabetics than in non-diabetics (P=0.0026, Fisher's test). VEGF protein was localized in both vascular endothelial cells and synovial lining cells. The mean number of VEGF-positive vessels and the vessel area were also significantly greater in the diabetics (P<0.015, Mann-Whitney U test). Synovial proliferation and shoulder joint contracture were more common in the diabetics (P=0.0329 and P=0.073, respectively; Fisher's test). The mean preoperative range of shoulder motion significantly differed in terms of elevation between the two groups: 103.8° in diabetics and 124.9° in non diabetics (p=0.0039 Mann-Whitney U test). These results suggested that VEGF121 and VEGF165 expression in the subacromial bursa was responsible for the development of shoulder joint contracture, especially in elevation, among type II diabetic patients with a rotator cuff disease.
The purpose of this study was to evaluate shoulder joint laxity in throwing athletes using stress radiography under general anesthesia and to compare them with the other methods for evaluating shoulder joint laxity. Stress radiography under general anesthesia was performed on 25 throwing athletes who underwent arthroscopic surgery. Anterior or posterior translational stresses were applied to the proximal humerus with the patient's arms in 90° abduction and neutral rotation, and axial radiographs of the glenohumeral joint were taken. The translation was shown as a percentage of the displacement of the humeral head with respect to the glenoid. Another three tests were performed, stress radiography in the awake condition, examination under anesthesia and load and shift test. We compared the results of these three tests with the results of stress radiography under anesthesia. Stress radiography under anesthesia revealed an anterior translation of 42.0% and posterior of 22.8%. In the awake condition, the anterior translation was 4.0% and the posterior was 13.9%. About posterior laxity the statistically significant relationship was identified between the stress radiography under anesthesia and all the three tests, but there was no relationship with the anterior one. Stress radiography under anesthesia revealed a large anterior laxity in throwing shoulders. This laxity was not exactly detected by other tests.
The purpose of this study was to clarify the surgical outcome of the painful throwing shoulders with partial rotator cuff tears. We retrospectively studied 18 baseball players ranging from sixteen to thirty-one years of age (average, twenty-two point one years old ). Ten pitchers and eight infielders were included. Arthroscopically, SLAP lesions were recognized in eight csases and posterosuperior labral injuries in eight cases. In these cases, internal impingement was revealed in nine cases. Arthroscopic resection of the torn and detached labrum was performed in seventeen cases, arthroscopic debridement for the articular-side partial rotator cuff tear (APRCT) was performed in nine cases, open cuff repair was performed in four cases, arthroscopic repair of the anterosuperior labrum was in four cases and thermal capsular shrinkage in seven cases. We evaluated the throwing pain and the function with the shoulder sports score of Japan shoulder society (sports score). Fifteen of the eighteen cases (83.3%) returned to their preoperative sports level from three to fifteen months after (average eight point four months). The average pain score at preoperation was 3.9points and the function score was 6.7 points. At the time of the last investigation, the pain score was 18.6 points and the function score was 31.7 points. The surgical outcome for painful throwing shoulders with partial rotator cuff tears were satisfactory.
A rotator cuff joint side tear is among the lesions that can be diagnosed through an arthroscopy. Our purpose was to study the mechanism of the rotator cuff joint side tear with x-rays in cases, which presented themselves with the contact of the labral tear.33 cases were studied that revealed lesions on both the superior labrum and the rotator cuff joint side diagnosed by arthroscopy. Operative arthroscopy presented a labral tear including 16SLAP lesions and 17 posterior superior labral tear. The contact between the rotator cuff joint side tear and the labral tear in operative elevation was recognized. The affected parts in the injured labrum and rotator cuff joint side tear were resected. Preoperative X-rays in elevation were taken as zero position of the shoulder joint in all cases. The 33cases consisted of 10 Type A,5 Type B, and 2 Type C.16 cases with no contact of vertical line and the glenoidal surface were classified as Type S. It was understood that if these cases are the humeral head slipping phenomenon. We considered the mechanism of the forced conflict of the labrum and the rotator cuff joint side by a humeral head slipping phenomenon that occurs when the rotator cuff approaches the superior glenoidal surface.
The zero position with external rotation is similar to the important skill in the throwing movement. We examined the correlation between the muscle strength of external rotation at zero position and the characteristics of the throwing motion in throwing shoulders. A prospective study of 17 throwing shoulders and 15 normal shoulders were examined. We evaluated the muscle strength of external rotation at zero position using MICRO FET by puppy position. We also examined the throwing motion using MOTUS (3D analysis system). From these examinations, we investigated the correlation between the muscle strength of external rotation at zero position and the characteristics of a throwing motion in throwing shoulders. The muscle strength of external rotation at zero position was 35.3N ± 8.4 in normal shoulders. The muscle strength was 19.8N ± 6.4 and under 30N in the majority of throwing shoulders compared with normal shoulders. We investigated the characteristics of the throwing motion in each group. They throw a ball using an extended motion on the elbow in the normal group. The majority of patients throw a ball using a rotated motion on the shoulder. Insufficient muscular strength of external rotation at zero position was the cause of the wrong motion of a throw. As a result in this study, the evaluation of the muscle strength of external rotation at zero position for the throwing shoulders was important.
A 2lyear old male has complained of right shoulder pain while pitching since he was 14 years old. He first noticed a discrepancy of the length of his right upper arm during junior high and the discrepancy aggravated according to his growth during his high school years. He had mild pain in the right shoulder, however, he was still able to continue to play baseball as a hobby. As he continued throwing, the pain progressed with limited abduction. He began avoiding weight-bearing on his right arm and arm raising became a difficulty. For these reasons, he was referred to our clinic with a humerus varus. On physical examination, there was a 4.5cm of arm length discrepancy. Active forward flexion was 120 ° and abduction was 90 °. Radiographs demonstrated a growth arrest of the proximal humerus with a 65 ° neck-shaft angle. An open wedge osteotomy of the humeral neck was performed. Adhesion between the deltoid and the proximal humerus was observed. Scarring of the soft tissue surrounding the medial proximal humerus and was also evident. The denseness of the surgical neck of the humerus was recognized. The neck-shaft angle improved from 65 ° before surgery to 138 ° after surgery. Valgus osteotomy of the humeral neck allowed an improved function of the arm with an increase in active abduction and forward flexion.
We reported on a rare case of a rotator interval rupture associated with a cuff tear caused by an active muscle contraction in soft-tennis. The patient was a 54-year old female who had a 30-year career of competitive soft tennis. When she hit a ball at the top position on her forehand, she felt a pop in her right shoulder. She did not feel any pain unless she tried to elevate her shoulder. She visited our clinic 5days after the injury and an operation was performed 12days after the injury. An avulsion of the antero-superior part of the labrum with a disrupted superior glenohumeral ligament was visible through arthroscopy. The reconstruction of the large cuff tear(30*30mm)was done by open procedure. Histologically, a hyalinization was found in the torn cuff stump. A full function of the shoulder was obtained at 6months after surgery. She returned to tennis at 7months and participated in a tournament lyear after surgery, but her abduction strength remained at 46.8% of the opposite site. This rotator interval rupture associated with an adjacent cuff tear might be caused by an excessive force of abduction external rotation and horizontal extension to the shoulder during hitting.
The purpose of this study was to present a rare case of recurrent posterior dislocation of the sternoclavicular joint(SCJ) with accessory nerve paralysis. A 67 year old man fell onto his right shoulder. At another hospital he underwent conservative treatment with a clavicle band under a diagnosis of anterior subluxation of the SCJ. When the band was taken off he felt pain in his throat So he came to our hospital 3 months after the trauma. There were no abnormal findings in the appearance of the SCJ. He felt pain when he kept his shoulder in the horizontal adduction position and discomfort in deglutition. He had a past history of his accessory nerve being injured at the time of a neck lymphadenectomy and his trapetius was remarkably atrophic. CTs showed subluxation to the posterior of the SCJ at horizontal adduction position. The diagnosis was posterior dislocation of the SCJ and the operation was performed eight months after the trauma to do reduction and reduce pain in deglutition. Although his shoulder was repositioned with his arm at his side, we confirmed his shoulder was dislocated posteriorly at maximum horizontal adduction as CT findings confirmed. The arthroplasty was performed using palmaris longus. Up to now there has been no recurrence. In this case, there was paralysis of the trapezius due to an accessory nerve injury. This paralysis affected his throat with its discomfort and pain. Paralysis of the trapezius leads to loose stability from the scapula to the thorax, which especially weakens the adductors and muscle strength that makes the scapula go downward. Consequentially, a proximal part of the clavicle was thought move posteriorly due to the scapula position at abduction and anteversion.
The purposeo f this study was to report on a case with late infectiona fter hemi-shoulder-arthroplas(tHyS A)and to discuss its diagnosisa nd treatment. A 61-y ear-o ld femaleh ad a 4 part fracture-dislocatioonf the proximal humerus due to a direct fall onto her shoulder. An open reductionw as performedb ecausea closed reductionh as not been successful. HSA was performed 3 weeks later. Howeverc, ontracture of the shoulder deterioratedo ver time due to an axillaryn erve palsy. Endoscopiscy novectomy was performed 2 years after HSA. She did well for 2.3 years. Then she suddenlye xperienceds wellingw ithoutp aina nd fever on the anterior part of the shoulder 4 years and 6 months after the HSA. Treatment combined with NSAID's, antibiotics, drainage and irrigation were not effective. A pus culturew as once positive, yielding CNS. Fistulectomy was performed 2 months later, but it was not effective. The prosthesis was removed on the basis of the findings of the MR arthrogram, and a cement spacer was inserted. Cultures obtained at the operation were all negative. Infection signs became negative one month later. After 4 months without signs of active infection, revision arthroplasty was performed. There were no symptoms or signs of infection 10 months after revision.
The patient, a twelve-years-old, male, was told he had a mass at the superior scapula at the time of a school medical check up. When we saw him he had a right superior angle of the scapula, which was touched by a tumor ( 4 × 5 cm). He did not have any subjective symptoms. We suggested osteocondroma, which occurred in the superior angle of the scapula by using X-rays. CTs and MRIs. We had trouble with the choice of surgery from because of the size and superior angle. We chose a posterior midline approach to avoid the damage of the accessory nerves. Next, we cut the trapezius and rhomboideus major and minor. The tumor was resected. Accessory nerve paralysis was not recognized after the operation. There was no tumor recurrence at one year after surgery. Osteocondroma, which occurs in the superior angle of scapula is rare. A posterior midline approach was chosen because of the occurrence and the size. This approach was a useful surgery, when the function of the accessory nerve was kept.
We presented a patient who had a posterior-dislocation fracture of the shoulder in an epileptic seizure. A 53year-old male with right side hemiplegia complained of pain and motor disturbance in his left shoulder after a seizure. X-rays and CT scans showed a posterior dislocation fracture of the left shoulder. Greater and lesser tuberosity fragments were displaced. A substantial bone defect of the humeral head accounted for approximately 40%. On the same day, the dislocation was reduced closely, and displacement of the lesser tuberosity fragment remained still. After one week, we performed an internal fixation of burst fragments of the lesser tuberosity into the humeral bone defect with suture anchors. Nine months after the surgery, he had flexion and abduction of 150 degrees, external rotation of 60 degrees, and internal rotation of Ll. The strength of the subscapularis muscle was “good” (MMT). No evidence of avascular necrosis of the humeral head was present. We performed a surgical procedure for the purpose of acquiring the function of internal rotation and anterior stabilization. In the future, he may have any occasions to support his trunk with his left upper extremity. Thus, we must be careful of the occurrence of a humeral head collapse due to weight bearing stress.
The purpose of this study was to investigate the clinical results of arthroscopic debri- dement with continuous irrigation in patients with septic arthritis of the shoulder. Eight patients (three men, five women) with septic arthritis of the shoulder treated with a combination of arthroscopic debridement, continuous irrigation and antibiotic therapy were followed-up for more than one year. Their average age was fifty-five years old (range: twenty five-seventy five). The causes of infection were injection of the intrasubacromial bursa in four cases, puncture of the electromyography needle in one and unknown in three. The S. aureus was cultured in four cases and the S. epidermidis in three. The follow-up period averaged thirty months (range: twelve to one hundred twenty one months). Recurrence of the infection did not occur in any case. The averaged shoulder score of the Japanese Orthopedic Association had increased from 25.2 points before operation to 87.1 points after operation. All but one had no motion pain and severe contracture of the shoulder joint. In our radiographic finding, two cases revealed a progression of the osteoarthritis of the shoulder. An arthroscopic debridement with continuous irrigation was an useful method in patients with septic arthritis of the shoulder.