There have been a few studies on the histology and morphology of the glenoid labrum. We observed the histological and morphological differences depending upon the part of the glenoid labrum. Specimens were obtained from 8 cases 12 joints from autopsies. The mean age of specimens was 80.3 years old (36-103). After macroscopic observation, the glenoid with labrum was fixed in 10% formaldehide and decalcified. The glenoid was divided into 6 pie-slice pieces by radial incision and parafin sections were made. The sections were stained by hematoxyline eosin, Safranin-O and Azan-Mallory's procedure. The morphology of the glenoid, the extent of the fibrocartilagenous area (FCA) and the attachment site were observed. The superior labrum had strong connection to the long head of the biceps tendon and wide FCA. The anterosuperior labrum had small FCA with a narrow attachment to the glenoid and appeared meniscus-like in shape. The anteroinferior labrum had wide FCA and attachment site and appeared meniscus-like in shape. The inferior and posterior labrum had moderate size of FCA and attachment site and appeared round in shape without a free edge. The glenoid labrum had a wide variation in histology and morphology according to the present study. These results provided useful information for anatomical repair of a labrum injury.
The purpose of this study was to clarify the etiology of the Bennett lesion anatomically. Bennett reported in 1941 that stress of the posterior capsule and the triceps long head resulted in the development of spur at the posterior and inferior glenoid edge, but the mechanism of this lesion is still controversial. We studied 25 shoulder joints from 20 cadavers. All shoulder joints were revealed from the posterior aspect in order to investigate the anatomy of the posteroinferior part of the glenoid. We noted the origin of the triceps long head and the attachment of the posteroinferior capsule. The upper border line of the triceps was noted in terms of the face of a clock in a right shoulder. The triceps and the capsule were investigated histologically at the 8 o'clock position. The triceps originated from 7: 30 to 9 o'clock positions of the glenoid. The posterior capsule was attached to the glenoid rim with the labrum located less than 1 cm from the glenoid edge. This anatomic study demonstrated that the location of a Bennett lesion coincides with the origin of the triceps long head. The posterior capsule attached only at the edge of the glenoid. We therefore considered that the triceps is more associated with a Bennett lesion than is the posterior capsule.
[Purpose]The purpose of this study was to evaluate the activity of shoulder muscles in the abduction and external rotation motion of the shoulder and to find out the appropriate motion for the exercise of the inner and outer muscles. [Materials and Methods]We examined the non-dominant side of the shoulders of 10 adult males who did not have any shoulder disorder. We pasted surface electrodes for 9 outer muscles and stuck needle electrodes into 3 inner muscles of each subject. Each person performed an isokinetic abduction(range: 0-135°)and an extemal rotation motion(range: IR45-ER30°)in various loads with a Cybex. We obtained an electromyogram of each muscle. [Results and Conclusions]The abduction motion in the initial range with a low load, produced a higher activity of the supraspinatus muscle(SSp), so the exercises in such like motions were considered to be specific for SSp. The external rotation motion in the initial range with a low load, produced higher activities of the 3 inner muscles, so the exercises in such like motions were considered to be appropriate for exercises of the inner muscles. When abduction and external rotation motion were done with a high load or in the end range, activities of the outer muscles were as high as that of the inner muscles, so the exercises in such like motions were considered to be appropriate for a combined exercise of the inner and outer muscles.
Flattening and/or anterior subluxation of the long head of the biceps tendon (LHB) is frequently seen in patients with a rotator cuff tear, which has been proposed by some surgeons to be the cause of shoulder pain. We evaluated the condition of the LHB in patients with a rotator cuff tear using a multi-reconstructed CTarthrography method. For the present study, we evaluated 24 shoulders in 23 patients who were diagnosed as having a rotator cuff tear, for which surgery was performed from May 2002 to September 2004. Patients with a complete tear of the LHB were excluded from this study. We carefully evaluated the condition of the LHB (LHB width, partial tear condition, and subluxation) during surgery and classified the patients into 3 groups, those without obvious pathological findings (Group N, n=10 shoulders), those with a flattened and/or partial tear of the LHB without subluxation (Group F, n=8 shoulders), and those with a subluxated LHB (Group S, n=6shoulders), based on our intraoperative findings. Oblique-sagittal reconstructed CT-arthrography images were used for the analyses. We defined percent length as the relative length between the joint surface margin and anterior edge of the LHB as the ratio of the length between the joint surface margin and the tip of the lesser tuberosity. The mean percent length in Group S was significantly greater than in the groups without an LHB subluxation. Further, there was a significant correlation between percent length and width of the LHB. The mean percent length in Groups N, F, and S was 16.5%,32.8%, and 79.0%, respectively, which were significantly different. We found that the results for percent length using reconstructed CT-arthrography images were related to intraoperative findings for the LHB, which showed that the present method is useful for preoperative evaluation of the LHB condition
The purpose of this study was to investigated the efficiency of the radial plane of MR arthrography(MRA) for superior labral lesions in a painful throwing shoulder. The twelve painful throwing shoulders were examined. Age of the patients were 16-33 years old (mean 21.3 years old ) and patients had either signs and symptoms of superior labral lesions. Each patient underwent a radial MRA after intra-articular injection of 10ml of 0.5% mepivacaine. Superior labral lesions of all patients were categorized according to Yamasaki's classification, and the findings on the MRA were correlated with the arthroscopical findings. MRA was performed with 1.0-T system (SIEMENS HARMONY). All patients were supine with the humerus in the neutral position. After a radial localizing imaging, intensity and morphological changes in the labrum through all the o'clock positions of the glenoid rim in T2 star images by the FRASH method were evaluated. When we diagnose Type II-B, type III or type IV as a superior labral lesion, this study showed 87% of sensitivity,78.9% of specificity, and 81.3% of accuracy through all the o'clock positions of the glenoid rim on the radial plane of MRA. A radial MRA was useful to diagnose the superior labral leision in painful throwing shoulder. Though 0.5% mepivacaine is cheaper than gadopentetate meglumine, it did not influenced the enhancement effect.
The purpose of this study was to investigate the MRI images of the rotator cuff muscle to determine the images properly reflecting the muscle volume. We obtained MRIs of 30 normal shoulders. (T1-weight, slice thickness 5mm, spacing 0mm) and assessed the cross-sectional area in the following 3 groups; 1)supraspinatus(SSP) 2)infraspinatus and teres minor (ISP)and 3)subscapularis(SUB). The muscle volume in each groups was obtained by integration of the cross-sectional area. We set up three kinds of ratios (ISP/SSP, ISP/SUb and SUB/SSP) and calculated the correlation between The cross-sectional area and the muscle volume using the ratio. There was a strong correlation(p<0.01) of the cross-sectional area on the MRI image between 30mm and 40mm medially to the articular surface. The strongest correlation was seen on the image obtained 35 mm from the articular surface. This correlation was independent of the size of the scapula bone itself. The crosssectional MRI image 35mm from the articular surface well represents the volume of the rotator cuff muscle.
The bonesetter's treatment for shoulder dislocation still remains unknown. The purpose of this study was to investigate the bonesetter's treatments for shoulder dislocations. A questionnaire included the following items: (1) reduction method for a shoulder dislocation (2) immobilization method (3)immobilization time was sent to 140 bonesetter's institutions in Akita. The response rate of the questionnaire was 32.1% (45/140). The most frequently used reduction method was the Hippocratic Method 51%, followed by Kocher's Method 44%, the zero position traction Method 38% and other methods 9% such as the adduction abduction method, the horizontal rotation method, DePalma's Method. The Hippocratic Method was the first option for a Judo related shoulder dislocation. The immobilization method was bandage with sling in 60%, with Desault's method in 22%, only sling in 11%and splint with sling in 7%. All immobilization was in the internal rotational position. The average immobilization period was 2.8 weeks (one to six weeks). The immobilization period was foe more than five weeks in 2%, one week in 2 %, four weeks in 11%, two weeks in 33% and three weeks in 51%. The Hippocratic Method was the most popular reduction method among bonesetters. All shoulders were immobilized in internal rotation after a reduction. The average immobilization period was 2.8weeks.
We operated on first shoulder dislocations with a cuff tear on older patients at the early stage. This is a report of the results of the surgery. The patients were 5 cases with an average age of 69.6 years-old. The average duration from onset to surgery was 5 weeks. The numbers of shoulders were 4 with a middle rotator cuff tear and 1 with a massive rotator cuff tear. A boney Bankart's lesion was found in 1 case.3 patients were treated by McLaughlin's procedure,1 by the palmaris longus graft and 1 by Bristow's procedure. All the patients were evaluated by the JOA score (total 80 points). The average JOA score after surgery was 70.6 points.4 patients were satisfied and 1 complained of pain at the rotator interval. We considered that McLaughlin's procedure for first shoulder dislocations with a cuff tear is effective to reconstruct the shoulder joint, and Bristow's procedure is a successful treatment for a boney Bankart's lesion.
The purpose of this study was to investigate the clinical characteristics of shoulders with traumatic anterior instability. In 1998-2003, we surgically treated 62 shoulders in 62 patients with traumatic anterior instabilities of the shoulder. The subjects consisted of 45 males and 17 females with an average age of 24.1 years old. Sixty-two shoulders were divided into two groups: group S, which consisted of 29 shoulders diagnosed as recurrent subluxation and group D, which consisted of 43 shoulders diagnosed as recurrent dislocation. Furthermore, group S-D, which consisted of 19 shoulders shifted from subluxation to dislocation was included in group D. We investigated the following points: scoring system for joint hypermobility (Beighton), the applied force at the initial dislocation, the number of dislocations or subluxations, and the age at the initial dislocation or subluxation. Furthermore, Hill-Sachs lesion and Bankart lesion were evaluated using CT images. The grade of the Hill-Sachs lesion of group D and group S-D was more severe than it was in group S. The degree of the Hill-Sachs lesion therefore might suggest migration from subluxation to a clear dislocation.
The purpose of this study was to review by preoperative images whether a diagnosis ot HAGL lesion was possible in traumatic shoulder instability. As a cause of anterior shoulder instability, Bankart's lesion is known well, but humeral avulsion of the glenohumeral ligaments is not known very much. Between July 2002 and March 2004, we performed arthroscopic surgery to 36 shoulders in 36 patients with traumatic shoulder instability in our hospital. All were included in this study. There were 29 men and 7 women whose average age was 22.3 years old (16-39 years old). We evaluated HAGL lesions by plain radiograph, arthrography and MR arthrography of the shoulder under a blind name and an ID number, and compared these with our arthroscopic finding of the shoulders. There were HAGL lesions in 4 of 36 shoulders by arthroscopic findings.4 shoulders showed positive findings of an HAGL lesion on preoperative images and 3 of these were judged HAGL lesion by arthroscopic findings (sensitivity 75%).32 shoulders did not show positive findings of an HAGL lesion on preoperative images and 31 of these were not judged to have HAGL lesion by arthroscopic findings (specificity 96.9%). Then the above, the false positive rate was 3.1%, the false negative rate was 25%, the positive reaction hitting rate was 75%, and the negative reaction hitting rate was 96.9%. An HAGL lesion is a cause of shoulder instability, so we should evaluate the presence ofHAGL lesion by preoperative images in addition to Bankart's lesion.
The aim of this study was to report the genesis and the problems of locked shoulder dislocations. We evaluated the results of treatment in 24 patients with 24 locked shoulder dislocations, in 13 men and 11 women, that had gone unreduced for at least 3 weeks. Their ages were 21-83 years-old (average 51 years-old).16 dislocations were anterior and 9 were posterior. The period from the injury to beginning our treatment was from 3 weeks-47years. The causes of locked shoulder dislocations were various.1 case was complicated with severe trauma, there was no other way and treatment was delayed.2 cases were ones of self judgment. The most important fact was the 21 remaining cases had problems in diagnosis and the treatment at their medical institutions. A lot of cases of locked shoulder dislocations had a missed diagnosis by their medical institutions was clear. We think that an accurate injury is diagnosis and enough observation of the passage of time are important.
The hook plate (Best Ltd. ) was used for the patients with acute acromioclavicular dislocation in twelve patients. The average age of the patients was 31.9 years old (range 20 to 58 years old). All patients were male. Eight patients showed a Rockwood type III dislocation, and four showed a Rockwood type IV intheir initial Xrays. The surgical procedure involved removal of the distal end of the clavicle and reduction of the AC joint with the hook plate without transposition of the coracoacromial ligament. Postoperatively, all patients were encouraged to use the arm as normally as possible, but were discouraged from overhead work and sports. The plate was removed after 3 months. The mean follow-up was 22 months. Overall subjective satisfaction was good in all cases. In the operated shoulder with the hook plate, the average flexion was 127 (80-160) and external rotation at side was 77 (60-80). After the plate removal, the average flexion was 166(150-170), and the average external rotation at side was 83(70-90). There was a mean of 1.4 (0-5) mm of correction loss in X-rays between the shoulder with a hook plate and the shoulder after the plate removal. The hook plate provides secure anatomic reduction and early return to daily living without immobilization. After the plate removal, the shoulder without the coracoacromial ligament transfer did not show a significant correction loss of the AC joint.
The aim of this study was to evaluate whether preoperative diagnosis by MR orthography (MRA) was possible or not. It has been reported that preoperative diagnosis of HAGL lesion and capsular tear (CT) was difficult until now. However, these treatments are completely different in case of Bankart lesion. Therefore preoperative diagnosis is very necessary. A prospective review of 166 cases of traumatic shoulder anterior instability diagnosed at our institution from July 1999 to September 2004 was performed. All patients had undergone MRA before arthroscopy. There were 157 men and 36 women (mean age 24.4years old). Gd-DTPA in saline was instilled into the shoulder joint and then MRA was performed at 1.0T in the several planes. A routine protocol uses T2 (oblique coronal and oblique axial at ABER position) and fat-suppressed T1-weighted images in four planes (oblique coronal, axial, oblique sagittal and oblique axial at ABER position) post injection. The MRA criteria for the diagnosis of an HAGL lesion are dilatation of the inferior pouch and extravasion of contrast material across the torn humeral attachment on the oblique coronal and axial plane (or oblique axial at ABER position). The criteria for a CT are discontinuity of the capsule and extravasion of the contrast material from the part of the capsular tear on the oblique coronal and axial plane (or oblique axial at ABER position). The finding that the glenohumeral ligament remains intact on the glenoid rim was used as supporting diagnosis. All HAGL lesions (5 cases) were detected on MRA finding (sensitivity 100%, specificity 100%, and accuracy 100%).6of 8 CTs were detected on MRA finding (sensitivity 75.0%, specificity 99.5%, and accuracy 98.4%). A high diagnosis rate was provided in both. HAGL lesion and capsular tear were important causes of anterior instability of the shoulder. Preoperative diagnoses of both lesions was possible and useful by MRA findings.
The aim of this study was to examine the clinical results of arthroscopic Bankart repair using absorbable anchors (PANALOKTM) for traumatic recurrent anterior instability.35 shoulders of 34 patients were managed with this procedure. There were 28 men (29 shoulders), and their mean age was 27 (16-64) years old. The average follow-up period was 22 (9-47)months. In principle, this arthroscopic procedure was performed when the anterior band of the inferior glenohumeral ligament (AIGHL) with sufficient width was clearly observed. The average number of anchors was 2.8 (2-4). There were 3 exceptional shoulders without sufficient AIGHL.4 shoulders had dislocation again after surgery caused by an injury while snowboarding. In the residual 31 shoulders, the average JOA score at the point of latest follow-up was 97.0 points (28.5 of pain,19.9 of function,28.6 of ROM,5.0 of radiographic evaluation, and 14.5 of stability), and average JSS Shoulder Instability Score was 94.6 points (17.9 of pain,18.6 of function,18.0 of ROM,10.0 of radiographic evaluation, and 29.4 of stability). Goodfunctional results may be expected from arthroscopic Bankart repair using absorbable anchors.
The purpose of this study was to evaluate the results of Caspari's method using non-absorbable sutures and buttons for a recurrent anterior dislocation of the shoulder.54 shoulders in 54 patients who underwent Caspari's method were studied. The average age at operation was 25 years old. The postoperative clinical results were evaluated by JSS Shoulder Instability Score and Rowe's score. Moreover, the amount of bone defect in the glenoid at the 4 o'clock position and Hill-Sachs' lesion was measured using MRA, and the correlation between the amount of bone defect and redislocation rate were investigated. The mean JSS scores were 49.3 points before the operation and 92.3 at two years after the operation, indicating a significant improvement Rowe's scores were excellent for 40 patients, good for 10 patients and poor for 4 patients. A redislocation occurred in 4 patients. Bone defects in the glenoid were found in 16 patients(37%). The amounts of bone defects in the glenoid were less than one-quarter of the anteroposterior diameter of the glenoid (small bone defect) in 14 patients and one-quarter or more (large bone defect) in 2 patients. Redislocation occurred in 2 shoulders (100%) with a large bone defect The Caspari technique might not be effective for cases in which the amount of bone defect in the glenoid is one-quarter or more of the anteroposterior diameter of the glenoid.
Rotator interval (RI) closure has been commonly performed as an adjunct to arthroscopic stabilization of the shoulder. However, there has been no study to clarify the effects of RI closure. The purpose of this study was to determine the effects of RI closure on shoulder stability and motion. Fourteen fresh frozen cadaveric shoulders were used. The position of the humeral head was measured using an electromagnetic tracking device. The experiments were performed under the following conditions: capsular condition,1) intact,2) sectioned horizontally,3) imbricated between the superior glenohumeral ligament and the subscapularis tendon (SSC group) or between the superior glenohumeral ligament and the middle glenohumeral ligament (MGHL group); positions of the arm and directions of the translational load,1) anterior, posterior, and inferior translational loads with the arm at 0 degrees of abduction,2) anterior load in abduction/maximum external rotation in the coronal plane (apprehension position); load 1) 10,2) 20,3) 30 newtons applied to the proximal humerus. The range of motion was measured using a goniometer under a constant force using a force transducer. Both methods reduced the anterior translations in adduction. No significant effects were observed on the inferior translation or the anterior translation in the apprehension position. Both methods reduced the ranges of rotations and horizontal abduction. RI closure has a stabilizing effect on anterior/posterior translations in adduction. RI closure was expected to reduce remnant anterior/posterior instability and thereby improve the clinical outcomes of arthroscopic stabilization procedures.
The purpose of this study was to report on the minimum 6 month-results of arthroscopic repair of rotator cuff tears with Knotless anchors. Thirty-three shoulders arthroscopically treated with Knotless anchors were retrospectively evaluated. The average follow-up was 10.2 months, with a minimum of 6 months. This study group included 7 small tears (<1cm),21 medium-size tears (1 to 3 cm),4 large tears (3 to 5 cm) and 1 massive tear (> 5cm). Anchors were the primary method of arthroscopic fixation, with an average of 2.0 anchors per case. Additional side to side sutures were performed in 7 cases. The clinical results were evaluated using a Japanese Orthopaedic Association (JOA score), shoulder scoring system. Radiographic evaluation revealed early failures of Knotless anchors were pulled out in three cases at 4 weeks postoperatively. The JOA scores of the group without three failure cases increased from a preoperative average of 61.7 to a postoperative average of 82.3 at 3 months and 91.3 at 6 months respectively (P <0.05). Patients treated with arthroscopic rotator cuff repair with Knotless anchors showed excellent short-term clinical outcomes minimum 6 months after surgery. However, patients' selection was crucial to decrease the number of early Knotless anchor failures.
The purpose of this study was to evaluate the differences in clinical course and functional recovery between arthroscopic (ARCR) and open repair (ORCR) for rotator cuff tears. I evaluated 30 patients with ARCR (17 men and 13 women, whose average age at surgery 64.6 years old), and 30 with ORCR (22 men and 8 women, whose average age 66.4 years old). Preoperatively and at the time of follow-up (at a mean of 14 and 19 months respectively), the patients were assessed with Japanese Orthopaedic Association (JOA) shoulder scores. The patients' backgrounds in the two groups were not uneven. Symptoms, active range of motion and JOA shoulder scores of all patients improved after surgery (p<0.0001). Active elevation improved significantly at 12months after surgery, from a preoperative mean of 100° to 173° in the ARCR group, and likewise in the ORCR group (89° to 157° ), whereas postoperative external rotation at that time in the ARCR group improved better (28.3° to 61.0° ) than ORCR group (19.3° to 51.3° ). The average JOA shoulder score at 12months after surgery increased significantly, from 54.1 preoperatively to 96.5 postoperatively in the ARCR group, and likewise in the ORCR group (from 50.7 to 96.4). The ARCR group tended to have less perioperative pain, but no statistical significance was found in the indicators of perioperative pain in the two groups, since all of the patients had received adequate pain control using a continuous cervical epidural block. Postoperative stiffness and shoulder function at follow-up were similar, whereas the ARCR group improved quickly (p<0.0001) in the immediate postoperative period (shorter waiting period of physiotherapy after surgery, duration of bracing and better early range of motion) and less frequently complicated CRPS. I concluded that the ARCR group improved quickly and reduced complications in the immediate postoperative period.
The purpose of this report was to study the postoperative complications of internal fixation with an intramedullary locked nail (Polarus nail). Thirty-one patients (24 females,7 males) with fractures of the proximal humerus were treated by a Polarus nail. The mean age was 69.2 years old (range 21 to 93 years old). They were operated on within an average of 8 days after the being injured. The range of follow-up period was 6 to 43 months (mean 23 months). Clinical and radiological bone union was confirmed in 28 patients. The mean score of the clinical outcome was 76 (range 40 to 100 points) evaluated according to the Japanese Orthopaedic Association. Of 31 fractures,10 had postoperative complications. Three implant complications including proximal fixation screw loosening (5 cases), screw broken (2 cases) and proximal protrusion of the nail (4 cases)caused valgus neck deformity in 7 patients. A Polarus nail can be an effectiveimplant for the treatment of proximal humeral fractures with certain fracture types because of its less invasive and strong fixation. However, a relatively high number of complicationsin our series resulted from our surgical technique, osteoporoticbones and the implant itself. Adequate surgical methods especially for the nail insertion and modifying the implant were crucial for preventing a fixation failure or fracture displacement.
Nonunion of the proximal humerus is one of the difficult problems in shoulder surgery. From 1996, we performed interlocking intramedullary nailing in the treatment of proximal humerus nonunion with a straight nail system. The objective of this study was to investigate the clinical results of this procedure in patients with proximal humerus nonunion. We were able to investigate fourteen patients with a proximal humerus nonunion. Their average age was 72.9 years old. One patient was injured in the brachial plexus, so she was excluded from the functional assessment. All but two were treated conservatively as the initial treatment. Interlocking intramedullary nailing was performed with the straight nail system. A bone graft was added in all cases. Postoperative range of motion exercises were started a week after the surgery. The average follow-up period was 32.9 months. A bone union was achieved in all cases without any malposition of the nonunion site. All cases had improved the ROM of the shoulder and were satisfied with their surgical results. The average flexion of the shoulder was 120 degrees and the average external rotation was 35 degrees. Osteoarthritis of the shoulder had not progressed in any case. Interlocking intramedullary nailing using a straight nail system was enough to unite the nonunion site with early motion exercises.
We have treated operatively 10 patients with the comminuted fractures of the glenoid of the scapula The purpose of this study was to introduce our method and to evaluate the results of the surgical treatment for these patients. This study was composed of 10 patients, all were males. Their ages ranged from 38 to 78 years old (average: 55.7 years old). All the cases had large displacement of the intararticular fracture and incongruity of the glenohumeral joint Associated injuries in the shoulder girdle were as follows; anterior dislocation of the shoulder was 1 case, posterior dislocation of the shoulder was 4 cases, dislocation of the acromioclavicular joint was 3 cases, fracture of the clavicle was 5 cases, fracture of the coracoid process was 4 cases, and fracture of the acromion was 1 case. The operative first step was reduction and fixation of the intraarticular bone fragments with screws. The second step was connection between the glenoid and the scapular body with screws or plate. The final step was reduction and fixation of the associated injuries. At one week after the operation, passive ROM exercises were started. All the cases healed primarily and showed normal shoulder function. There were no infection or incongruity of the glenohumeral joint. The average JOA score was 96.4points and good functional results were obtained. The comminuted fractures of the glenoid of the scapula should be treated with the following plans: (1) reduction and fixation of the intraarticular bone fragments with a screw (2) connection between the glenoid and the scapular body with screws or a plate (3) reduction and fixation of the associated injuries. For comminuted fractures of the glenoid of the scapula, anatomical reduction, rigid fixation and early rehabilitation were necessary to get good functional results.
Although good mid-term clinical results aftera rotator cuff repair have been reported, it was pointed out that complete tendon reattachment to the humerus is very difficult. Growth factor administration has a potential to accelerate the tendon healing. The objective of this study was to investigate the effect of growth factors on cells derived from rotator cuff. The cells were harvested from the ovine infraspinatus tendon by an enzyme digesting method. Three kinds of concentrations of bFGF, EGF, IGF, TGF1 and PDGFAB were used in this study. Growth curve, cell proliferation rate using 3H-Thymidine incorporation, and gene expression of type I, III, and CTGF were evaluated after a single administration of growth factors. Furthermore, to investigate the effects of growth factors on biomechanical properties, selected growth factors were administrated with 2×105/ml cells and 20×32mm size of PGA mesh as a bioabsorbable scaffold. Biomechanical testing using an Instron testing machine was done after 1,2, and 3weeks culture. The cell numbers were compared at the time point of 7 days. Ten ng per ml EGF group was significantly increased in numbers. The thymidine incorporation results suggested a significant proliferation effect of adding growth factors except one ng per ml IGF group. The results of gene expression of type I collagen after 48 hours revealed a dose dependent negative effect on bFGF, a dose dependent positive effect of TGF β 1. In type mcollagen, almost the same results were obtained. Breaking strength of no growth factors group was markedly decreased after a 3-week culture. However, the results of EGF and/or TGF β 1 show a significantly strong breaking strength at 3 week. EGF had a stimulatory effect on prolifbration and TGF β 1 had a dose dependent effect on secretion of collagen. Although this study could not directly suggest the effect of growth factors on a rotator cuff repair, these results were useful to further in vivo study and regeneration study of the rotator cuff in vitro.
The purpose of this study was to evaluate the functional results after surgical repair of rotator cuff tears using the rate of improvement for muscle force of shoulder abduction. Thirty-eight shoulders in 38 patients with a rotator cuff tear underwent cuff repair. Abduction power of the shoulder was evaluated with spring scale preoperatively and 6 months after operation. There were 29 males and 9 females. Their averaged age was 61.2 years old. Duration of symptoms averaged 28 months. Twenty-nine patients had obvious trauma. Eighteen patients had a subacromial spur. Based on the intraoperative tear size, patients were classified into 2 groups (S group: partial thickness tear and full thickness tear<3cm, L group: full thickness tear≥3cm). Using the rate of improvement before and after surgery, we compared the results with sex, age, duration after tear, with or without subacromial spur and trauma and tear size. There was a significant difference in abduction power of the shoulder between the trauma group and the non-trauma group. The surgical outcome after a rotator cuff repair in the trauma group was better than that in the non-trauma group.
The purpose of this study was to evaluate the clinical results after surgical repairs of the rotator cuff tear with time.24 shoulders in 24 patients with a rotator cuff tear underwent cuff repair and were followed up for 2 years postoperatively. The mean age of the patients was 59.7 years old. There were 22 men and 2 women. A complete rotator cuff tear was found in 20 shoulders and an incomplete one in 4. All patients underwent subacromial decompression and McLaughlin procedure except one with an incomplete tear. The patients were evaluated according to the JOA shoulder score and abduction power in pain, function, and ROM with time. A decrease of shoulder pain and functional improvement of the shoulder joint were observed 3 months after the operation, compared with that preoperatively. In comparison with preoperative status, ROM in the shoulder joint got worse 3 months after the operation and improved one year and 6 months postoperatively. Abduction power 6 months after postoperation was greater than the preoperative power. After a rotator cuff repair, improvement in range of motion was slow, compared with that in pain, shoulder function and abduction power.
The purpose of this study was to evaluate the clinical results after arthroscopic rotator cuff repair (ARCR) for rotator cuff tears. We evaluated 11 patients (7 males and 4 females) who had one of their shoulders treated for a rotator cuff tear, using the ARCR, from February 2003 and were consequently followed-up for more than 6months postoperatively. The affected shoulder was on the dominant side in 6 patients and on the non-dominant side in 5 patients. The average age at operation was 61.5 years old (46 to 78 years old); the mean pre-operation period was 9.4 months (1 to 36 months); and the mean follow-up period was 13.4 months (9 to 19 months). We arthroscopically performed subacromial decompression and sutured the torn cuff to the greater tuberosity using suture one or more anchors, or repaired it with side-to-side sutures in U-shaped tears. We put the arm on a shoulder abduction brace for 4 weeks. For clinical follow-up, we used the Japanese Orthopaedic Association score (JOA score). The tear type was incomplete in four shoulders, small in three, medium in two, and large in two. According to the JOA score, the average total score increased from 62.5 points to 91.1 points. The average scores of pain, function, and motion improved from 9.5 to 23.6 points, from 12.4 to 19.3 points, and from 22.6 to 28.1 points, respectively. Two patients had moderate pain in ADL, and had shoulder contracture. The clinical outcome of the ARCR was almost satisfactory.
We assessed the clinical outcome of treatment for the rotator cuff tears with axillary nerve palsy after an anterior shoulder dislocation. Five cases of rotator cuff tears with axillary nerve palsy have been treated since 1996. The cases were 4 males and 1 female, with an averaged age of 61 years old. The mean follow-up period was 40 months. The duration from trauma to surgery ranged from 5 to 35 weeks. One shoulder had a massive rotator cuff tear and 4 shoulders had global rotator cuff tears. Two shoulders treated by simple rotator cuff repair and three shoulders were associated with patch graft of tensor fassia lata. All patients were evaluated by the shoulder score of the Japan Orthopaedic Association (JOA score). The average postoperative JOA score increased from 37 points to 82 points. The clinical results were excellent in 2 cases, good in 1, fair in 1, poor in 1. The main factor of a JOA score demerit mark was range of motion, and subsequently was pain. There was a correlation between the postoperative JOA score and the duration from trauma to surgery. In the treatment of rotator cuff tears with axillary nerve palsy, the early repair of a rotator cuff tear after improvement of axillary nerve palsy was important to gain satisfactory functional results.
To present a retrospective study on the outcome of treatment of the massive, irreparable tears of the rotator cuff by arthroscopic cuff debridement limited subacromial decompression in which the coracoacromial ligament was left intact in order to preserve the integrity of the coracoacromial arch and creating a smooth, congruent acromiohumeral articulation by removal of exostoses of the greater tuberosity which we call GTplasty. Twelve shoulders with pain that had massive, irreparable tears of the rotator cuff and greater tuberosity impingement were managed by these arthroscopic treatments. The average age of the patients was 69.3 years old. The average duration of follow-up was 29 months. The JOA score was improved from an average score of 60.5 points preoperatively to 84.6 points postoperatively (P=0.003). The evaluation of pain by visual analog scale reduced from an average score of 7.2 points preoperatively to 1.1 points postoperatively (P<0.001). Whereas, the patients had some persistent weakness, but satisfactory relief of pain and improved, range of motion were achieved. The arthroscopic cuffdebridement, limited subacromial decompressionand GTplasty could provide good pain relief and improved upper extremity function as the treatment of a patient with massive, irreparable tears of the rotator cuff.
Preoperative tests on rotator cuff tears are generally performed using arthrograms, ultrasounds and MRI. We performed photographic evaluations using preoperative x-ray and bone scintigraphy and reported on our assessment also whether prognoses are possible. The subjects were seventy-four shoulders with 73 cases of rotator cuff tears. The maximum diameters of the tears were measured during operation, and classification of them according to their sizes revealed 10 shoulders with small tears,34 shoulders with moderate-sized tears,18shoulders with large tears and 12 shoulders with massive tears. The average ages of the patients at the time of operation were an average of 60.6 years old (39 to 78 years old). Photographic evaluations using preoperative xray images and bone scintigraphy were performed. X-ray images were taken of humeral articulations in 2directions in order to learn the present arthrosis changes, and were evaluated according to the Gerber classification into four grades. Bone scintigraphy was used to classify and evaluate diffuse type and limited type. Additionally, the postoperative results were evaluated using JOA score. Although the grade of the osteoarthritis changes using x-ray photographic evaluations tended to advance progressively as the tear size became larger. Bone scintigraphy revealed that the limited form tended to decrease as the tear size became larger while the diffuse form tended to increase. X-ray photographic evaluations suggested the potential that osteoarthritis changes would advance the larger the tear size became, even if there were slight arthrosis changes, based on the results of the bone scintigraphy.
The purpose of the present study was to elucidate the histologic alterations in the course-after injury of torn cuff stumps, which had limited degenerations. Thirty- four cuff specimens from 34 patients aged from 40 to 59(average 47 years old) with traumatic complete rotator cuff tears were examined. The interval between the trauma episodes to surgery was from 0 to 40 months (average 6.7months). Specimens were taken from the torn cuff stumps and fixed in the 4% paraformaldehyde/ PBS and embedded in paraffin. Specimens were cut vertically from the bursal side to the articular side and stained with haematoxylin- eosin (HE) and Goldner's trichrome. The sections were stained immunohistochemically with antibody against α-smooth muscle actin to clarify the vessels. The HE sections were classified into 4 types according to our previous report. The area of collagen fibers of the total area of the specimens with a low magnified filed were calculated with the aid of an image processor for analytical pathology (IPAP). The vessel density of the area adjacent to stumps was also calculated with an IPAP. All the specimens were classified to the compact (tendinous) or interstitial types and no fragmented nor fatty types were found. The average interval between the trauma episodes and surgery of the patients with the compact type and interstitial type was 10.4 and 6.2 months, respectively. Patients with an interstitial type was dominant in number after a 7 month post-injury period. The ratio of the area of collagen fibers did not vary regardless of the intervals. The number of vessels adjacent to the torn cuff stumps decreased gradually as the interval increased. These results suggested that the biological circumstances of torn cuff stumps for a tendon to bone reconstruction deteriorated in its course after the injury.
The purpose of this study was to examine whether thickness and fatty degeneration of the supraspinatus muscle will be recovered by cuff repair. McLaughlin's procedure was performed on 126 consecutive shoulders in 122 patients with a rotator cuff tear. The age of the patients ranged from 33 to 84 (mean 59.3) years. Eighty patients were men and fourty-six were women. Tears were classified by size of the tear intraoperatively after debridement according to DeOrio & Cofield's method. A small tear (less than 1 cm) and a moderate tear (1-3cm) were found in 54 patients, a large tear (3-5 cm) in 34, and a massive tear (>5 cm) in 38. MR images on the oblique sagittal plane were used for measuring the thickness of the supraspinatus muscle belly preoperatively and 2 years postoperatively, while the degree of fatty degeneration was classified into three grades using an oblique coronal plane image, according to the classification described by Nakagaki et al. Muscle belly of the cases where the size of the supraspinatus tendon tear was smaller and that of the cases where there was a low degree of fatty degeneration of the supraspinatus muscle belly thickness preoperatively improved significantly (p< 0.05). Recovery of the supraspinatus muscle belly thickness is expected where there is a small tear size of the supraspinatus muscle preoperatively and recovery of the fatty degeneration in the supraspinatus muscle belly is also expected where there is a low degree of fatty degeneration preoperatively. Therefore, we suggest that the surgical repair for a rotator cuff tear should be performed at an early stage.
A rotator cuff tear typically starts at the anterior insertion of the supraspinatus tendon, after which the defect propagates across the bicipital groove to the subscapularis tendon. Walch G. termed this type of lesion a hidden lesion. The purpose of the present study was to investigate the usefulness of CT-arthrography for evaluation of hidden lesions in patients with a complete rotator cuff tear. Seventy-two complete rotator cuff tear cases, whose subscapularis tendon insertion and long head of the biceps tendon pathology were fully evaluated during arthroscopy and/or open surgery, were studied. The patients' ages ranged from 37 to 76 years old, with a mean age of 60.0 years. In each, CT-arthrography and MRI results were obtained preoperatively, and the imaging protocols included the acquisition of axial and oblique sagittal. images. The sensitivity, specificity, and accuracy of CT-arthrography and MRI for diagnosis of the subscapularis tendon rupture were compared. Thirty-two (44.4%) of the cases showed a subscapularis tendon rupture with surgical confirmation. Of these,2 cases were an isolated rupture,14 were combined with a supraspinatus tendon rupture, and 16 were combined with both supra- and infraspinatus tendon ruptures. The sensitivity, specificity, and accuracy of CT-arthrography for diagnosis of the subscapularis tendon rupture were 83.3%,91.7%, and 86.7%, respectively, with the accuracy of CT-arthrography higher than that of MRI (79.5%). Further, the sensitivity of CT-arthrography using only the oblique sagittal plane (83.3%) was higher than that using only the axial plane (77.8%). CT-arthrography was found to be a reliable method for diagnosis of hidden lesions and sensitivity was high in the oblique sagittal plane images.
We evaluated the clinical outcome of arthroscopic rotator cuff repair (ARCR) in 10 patients who had partial rotator cuff tears (PRCT) in which more than 50% depth of the tendon was involved.10 patients who underwent ARCR from 2000 to 2003 were followed-up for 12 to 37 months (average 14.6 months). There were 6 males and 4 females with an average age of 62.9 years old at the time of surgery. All tears involved more than 50% depth of the rotator cuff.3 cases were bursal side tears, one case was intratendinous tear, and 6 cases were articular side tears. All patients received acromioplasty and rotator cuff repair artroscopicaly.3 patients who suffered from shoulder stiffness underwent arthroscopic capsular release. The results were evaluated according to the JOA shoulder score. The average postoperative JOA score increased from an average of 66.7points to 95.9 points at the time of the one - year follow - up. The pain score improved from 10.0 points preoperatively to 29.5 points at the time of follow-up. The function score improved from 14.9 points to 19.3points. The ROM score improved from 22.0 points to 27.1 points. There were few reports of the ARCR of PRCT which involved more than 50% depth of the tendon. In this study, the ARCR revealed good results as rated by the JOA score.
Basic treatment for rotator cuff tears is repair of the rotator cuff. However, in patients with small tears in whom the ability to elevate is sufficiently maintained despite a marked painful arc, we have not always performed repair of the rotator cuff, but have performed arthroscopic subacromial decompression (ASD), considering that ASD facilitates pain control and improvement in function. In this study, we reported on the treatment results, with a mean postoperative follow-up of more than 4 years. The subjects were 10 patients (10shoulders),7 males and 3 females, with a mean age of 56.9 years old and a mean postoperative follow-up of 54.7months. In all subjects, small tears were confirmed under an arthroscope, and an ASD was performed. Surgery was indicated for patients with small tears measuring 2 cm or less in diameter in whom active elevation was possible (including that after injection of a topical anesthetic). The mean preoperative and postoperative JOA scores were 64.8 and 92.9 points, respectively, with a 28.1 point increase. Concerning the patient's satisfaction, most patients lived in comfort, and a patient achieved rehabilitation as a professional kick boxer. (Conclusion) Arthroscopic suture for small tears has been reported; however, this procedure is not simple, and requires a long duration. ASD alone may achieve long-term good results in patients with small rotator cuff tears when it is adequately indicated.
Since frozen shoulder is characterized by spontaneous recovery, no precise treatment strategy exists. Conservative therapy is available, but the time required for recovery varies considerably. Nevertheless, there have been very few reports on drug therapy. In this study we found that it was possible to obtain early symptom relief with oral steroid therapy. There were 27 patients (12 males,15 females), and their ages at the start of treatment ranged from 33 to 67 years old (mean: 52.9 years old). A single course of steroid therapy consisted of a total dose of 105 mg of predonisolone over approximately a 3-week period by the dose-tapering method. The number of courses varied with the degree of symptom relief, but the rest period between courses was always approximately 4 weeks. The results of treatment were assessed on the basis of the JOA score, but the principal items assessed were pain and range of motion. Pain, including night pain and exercise pain, was noted in 26 of the 27 patients, but after a single course of treatment, it persisted in only 3 of them. The ranges of motion before treatment were 96.4° of anterior elevation and 9.6° of external rotation, and internal rotation was at the buttocks in almost every case. However, after one course of treatment, anterior elevation was 128.0°, external rotation was 30.5°, and internal rotation was limited to the buttocks in only 5 cases. After one course, in 13 of these cases anterior elevatiorl was 150° or more and the impairment of ADL had completely resolved. The results of oral steroid therapy of frozen shoulder were highly satisfactory. However, sufficient care is required in explaining the method of administration in cases where adverse effects exist, such as the development of femoral head necrosis.
The purpose of this study was to show that septic arthritis of the shoulder is uncommon compared with that of the knee and the hip. We reported on 4 cases of septic arthritis of the shoulder and considered the treatment with a little literature. From 2000 to 2004, we treated 4 cases of septic arthritis of the shoulder in our hospital. They consisted of 2 males and 2 females with an average age of 73.3 years old (range 68 to 76). All the cases had the predisposing factors. MRSA was cultured in 2 cases and MSSA was in 2cases. The interval between the onset and the start of treatment ranged from 3 days to 4 months. The follow up period averaged 11 months (range from 4 months to 2 years and 3 months). One case which had received treatment within 1 week following the onset was cured by repetitive irrigation. The postoperative JOA score was 89 points In 2 cases which had received treatment between 1 week and 2 weeks were successfully treated by debridement and continuous irrigation. The JOA score was 79 points and 61 points. In one case whose treatment was delayed more than 4 months, we could not treat it sufficiently by two debridement and continuous irrigation. Then we performed a musculocutaneous flap for a dead space. The JOA score was 30 points. A delay of treatment influenced the method of treatment and results. Debridement and continuous irrigation is effective in septic arthritis of the shoulder, but in one case whose treatment was delayed, more invasive treatment was required.
The purpose of this study was how to treat a superior labral cyst with SLAP lesions. A superior labral cyst was seen in six patients by preoperative MRI among twenty three patients on which an arthroscopic surgery was performed by diagnosis of SLAP lesions. There were 5 men and a woman with an average age of 28 years old(18∼43 years old). There were two type l SLAP lesions and four type 2 SLAP lesions in Snyder's classification. Weakness of the supraspinatus muscle was recognized when a cyst extended to the scapular notch in two cases. A small cyst of a diameter with 5mm was seen in two patients and a cyst of a diameter with 10mm was present in two patients on MRI. Type 1 SLAP lesions are treated with debridement of the frayed tissue and type 2 SLAP lesions were repaired using a PANALOK anchor arthroscopically. A cyst which extended to the suprascapular notch were excised by open surgery in two cases. In the other four cases, there was no treatment of a labral cyst. Four patients underwent MRI postoperatively. The preoperative JOA score was 74∼90 points(average of 82.5 points)and the postoperative score was 93∼100 points(average of 95.5points) in six patients. Histologically the labral cysts in two cases were ganglions, but in one patient where the MRI showed no ganglion in 1 year and 10 months after an operation.3 patients underwent MRIs at rest in 4cases after surgery with an average of 1.5 years. The labral cyst had disappeared in all their MRIs. We considered that a small labral cyst with a SLAP lesion can disappear by repairing the labrum arthroscopically without a decompression of the labral cyst.
The purpose of this study was to investigate the bone bruise around the shoulder, to which little attention has been attracted. For longstanding pain,22 shoulders diagnosed with “bruise and/or sprain around the shoulder”were examined using MR images. Bone bruise was defined as a diffuse high signal in the proximal end of the humerus on the T2-weighted MR images. The average period between the injury and MR imaging was 58 (2228) days. In addition,14 shoulders of first-time anterior dislocation were examined with MR images. The average period between the injury and MR imaging was 28 (4-113d) ays. In the “bruise and sprain” group, bone bruise was seen in 5 shoulders (23%), and microfracture of the greater tuberosity (GT) was found in another shoulder. The bone bruise pattern was observed only around the GT. At time of injury, the patients were forced to abduct the shoulder excessively or they got a bruise on the acromion when they abducted the shoulder slightly. Impingement between the GT and the superior glenoid rim or acromion was suspected as a mechanism of the injury. All patients recovered completely in several months without surgical intervention. In the “first-time dislocation” group, bone bruise was found only in two patients with a rotator cuff tear. They were older (61a nd 64 y.o. )t han other patients of this group (17-42y. o.; a verage 24 y.o. ). B one bruises may be present in some patients with prolonged pain after injuries around the shoulder, but good results may be expected without any surgical intervention.
The purpose of this study was to investigate the kinematic parameters related to the position of the upper arm at ball release. A hundred and thirty-two healthy male baseball pitchers were involved. A motion capture system (ProReflex MCU-500+, Qualisys Inc, Sweden) was used to measure the pitching motion. The subjects were separated into two groups according to the horizontal adduction angle of the shoulder at ball release; A: under 0 degrees(56 cases, aged: 16 ± 4.2 y. o, height: 1.7 ± 0.12m, weight: 61 ± 12.7kg), B: over 0 degree (76 cases, aged: 18 ± 5.8 y. o, height: 1.7 ± 0.13m, weight: 64 ± 14. Okg). The T test was used to compare the angular displacement of the shoulder and trunk among the two groups. The statistical significance was set at p<0.05. The maximal horizontal abduction and minimal abduction of the shoulder during the arm cocking phase showed significant differences among the two groups(p<0.05). At ball release, the forward trunk tilt, lateral trunk tilt and trunk rotation showed significant diferences (p<0.05). The kinematic differences among the two groups were present in the study. The anterior stress of the shoulder increased with the horizontal abduction of the throwing arm. The results of this study will be helpful to coaches and players to understand the mechanics of overarm pitching.
The aim of this study was to investigate the differences of range of motion of the shoulder between elementary school and high school baseball players. We studied 35 elementary school baseball players(group ES) and 46high school baseball players(group HS). Internal rotation and external rotation of the shoulder with the arm abducted 90°(2nd IR and ER), internal rotation with the arm flexed 90°(3rdIR), horizontal flexion(HF), gleno humeral abduction (Abd) were measured bilaterally. The measurements were compared between the dominant and nondominant shoulders. The differences between the dominant and nondominant shoulders were compared between group ES and group HS. In group ES,2nd IR,2nd total rotation,3rd IR, and HF were statistically less and 2nd ER was statistically greater in the dominant shoulders than in the nondominant shoulders. There was no statistical difference in Abd. In group HS,2nd IR,2nd total rotation,3rd IR, HF, and Abd were statistically less and 2nd ER was statistically greater in the dominant shoulders than in group ES. The differences between the dominant and nondominant shoulders in the 2nd IR,2nd total rotation,3rd IR, and HF were statistically greater in group HS than in group ES. It seems that the 2nd IR decrease in the dominant shoulders in group HS was caused by not only retroversion of the humeral head, but also severer posterior shoulder tightness than in group ES. A change in the 2nd IR& ER range of motion of the nondominant shoulder from elementary school to high school baseball players may reflect the decrease of retroversion of the humeral head with growth.
Increased external rotation (ER) and decreased internal rotation (IR) of the dominant shoulder (DS) compared to the nondominant shoulder (NDS) are frequent in throwing athletes. However, few studies have demonstrated when these changes occurred and how they developed. The purpose of this study was to determine when the side-to-side difference in shoulder rotation was present in baseball players, and to clarify the relationship between the degrees of rotation, and physical findings. One thousand eighty-nine baseball players and 423soccer players at elementary school and junior high school were investigated. The ER and IR, the general joint laxity, the crank test, and the sulcus sign were examined. A questionnaire regarding the position played, shoulder pain, and the progression of shoulder pain was used for the baseball players. The ER of the DS was greater than that of NDS from ages 10 to 15 in baseball players, and in ages 11 and 12 soccer players. The IR of the DS was less than that of NDS from ages 10 to 15 in baseball players, and from ages 10 to 12 in soccer players. The ER of both shoulders in baseball players with a general joint laxity was greater than in those without the general joint laxity. The IR of both shoulders in baseball players with a positive crank test was less than those with a negative crank test. The ER of both shoulders in baseball players with a positive sulcus sign was greater than those with a negative sulcus sign. There was a side-to-side difference in shoulder motion in elementary school baseball and soccer players, and in junior high school baseball players, while there was no side-to-side difference in junior high school soccer players. In baseball players, the results of the general joint laxity, the crank test, and the sulcus sign were related to the changes in IR and ER, respectively.
The aim of this study was to elucidate the relation between ball speed in pitching during a baseball game and the power of external rotation (ER) of the shoulders. Nineteen games, which were at the national inter high school baseball tournament games in Japan, in which the pitchers threw more than 100 times, and the ER strength before the tournament and after the games were measured, were included in the present study. The straight balls were decided by the ball speed data and video tapes of the games and a mean straight ball speed in the first 30 pitches and the last 30 were calculated. The relation between the changes of ball speed and ER strength were assessed. In 8 of 19 games, the ball speed decreased more than 3 km/h between the first 30pitches and the last 30 pitches and these games were classified into speed decreased game (DG), and the other 11 games were into non DG. The mean ratios of ER strength of the throwing side to the non throwing side were 1.02 in non DG and 0.99 in DG before the tournament. The mean ratios of ER power were 1.02 in non DG and 0.95 in DG after the games. The differences of ER ratios between before the tournament and after the game were +0.012 in non DG and -0.041 in DG, and a statistical significant difference was recognized between them. A decrease of straight ball speed during a game relates to a decrease of ER strength ratio. Maintaining ER strength could be one of the ways to keep ball speed in the game.
We reported that 50% of painful throwing shoulders with an internal rotation deficit (IRD) responded to the self-stretching exercises for posterior portion of shoulder. The purpose of this study was to examine the possible factors of residual pain of painful throwing shoulders with IRD who did not respond to self-stretching. We studied 47 throwing or overhand athletes (45 males and 2 females) with IRD, which revealed a significant posterior or inside the shoulder pain with a forced flexion/internal rotation, who performed self-stretching exercises for 2 months. Regarding the throwing pain after stretching, we divided the patients into 2 groups; 25whose pain completely disappeared into E group,13 who had a decreased or no change in pain into N group, and we examined the possible factors of residual pain. The average age was 21.0yo (E),25.1yo (N), the average throwing periods were 10.1 y (E),13.5y (N), which were significantly higher in N group than E group. IRD at 90degrees of abduction was 24.4°(E), 24.3°(N) before stretching, and 7.2°(E),18.2°(N)after stretching. IRD after stretching was significantly larger in N group than E group. Regarding the physical examination, the positive rate of forced ABER posterior pain, Crank test, and Komuro test were significantly higher in N group than E group. The positive rate of Bennett lesion assessed by X-ray and SLAP lesion assessed by MRI showed no significant differences. The present study proved it was important to consider the limitation of selfstretching for a painful throwing shoulder for older people, over a long throwing period.
The purpose of this paper was to evaluate the results of arthroscopic postero-inferior capsular release for a throwing shoulder with refractory posterior capsular tightness. We indicated this procedure for throwing athletes with throwing shoulders resisting against conservative treatment for at least three months and with over 20°loss of intenal rotation in the throwing shoulder with the shoulder at 90°abduction (2nd IR) or at 90°fiexion (3rd IR). We performed an arthroscopic capsular release using a bipolar radiofrequency probe and scissors from six to ten o'clock (for right shoulders). Five baseball players were retrospectively studied. Their mean age at surgery was 23.7 years old. There were three pitchers, one catcher, and one fielder. The mean follow-up period was thirteen months. Four of five patients could return to baseball after surgery at over 80%level of their pre-injury performance. The mean loss of 2nd IR improved from 31°to 7°, the mean loss of 3rd IR improved from 25°to 5°, and the differences were significant. Arthroscopic capsular release was effective for a throwing shoulder with refractory posterior capsular tightness.
The aim of this study was to report that we experienced a case that developed recurrent dislocation of both shoulders. The case was dislocated by a slight force. The case was a 74 year old woman. When she was going to close a sliding door in 1987, she was aware of a dislocation of her right shoulder. She was aware of a dislocation of her left shoulder in the way that she fell down stairs in 1990. She has often dislocated since 2003, and came to our hospital on October,2003. Apprehension tests were positive for both shoulders. She had a general joint laxity in Carter index 3/5. In X-ray, we had an OA change with both shoulders. An arthrogram and MRI showed a rotator cuff rupture. It did not show a Bankart, s lesion. Suture of the rotator cuff was performed in both shoulders. For 57 weeks after the postoperative day, right shoulder did not show a dislocation. For 42 weeks after the postoperative day, the left shoulder did not show any dislocation. Apprehension tests were negative for both shoulders. The postoperative observation period was short, but the person herself was satisfied. When we first thought about this case, we thought it would reject a Bankart lesion. Slipping phenomenon of the humeral head was presumed, because the case had a general joint laxity. It lost the function of joint stability with the rotator cuff tear, and that the humeral head slid into the scapular inferior margin.
The purpose of this study was to report two rare cases of combined Bankart lesion and SLAP lesion Type IV. Cases are two men (24 and 29 years old), and the causes of injury were a traffic accident and playing basketball. One case had motion pain and both had strong instability, and the anterior apprehension test and relocation test were positive. Arthrography, CT arthrography, MRI arthrography and 3DCT were performed, and Bankart lesion, Hill-Sachs lesion, and bony Bankart lesion were observed in both. SLAP lesion was not clear although joint mice were observed in one case. In the beach chair position, both arthroscopic views SLAP lesion Type IV and observed two joint mice were observed in one case. Although the arthroscopic Bankart repair using suture anchor was performed, to SLAP lesion, debridement was mainly performed and sutured in the direction of O'clock. One example had a large ablation of the upper labrum. Now have a postoperative two years and five months have passed, the these is no recurrence of dislocation and subluxation. The difference ( 5degrees and 15 degrees) only for external rotation in the first plane compared with the opposite side. Moreover, a return to sport was possible at a postoperative seven months. In MR arthrography and other imagings before an operation, diagnosis of the upper labrum injury was difficult, and both were diagnosed for the first time with an arthroscope.
Three months ago, a 73-year-old woman fell down, and received conservative treatment for a valgus impacted fracture of the proximal humerus at an orthopaedic clinic. She visited our clinic complaining of severe limitation of ROM in her shoulder and residual pain at night that interfered with sleep. The patient suffered from a mental disorder, insomnia and was getting medication from a psychologist. At first examination the ROM was 70 degrees in elevation, in external rotation 10 degrees and Th12 in internal rotation. In the X-rays, the humeral head shifted downward, leaving the greater and lesser tuberosities in a comparatively elevated position. In the MRIs, it was thought that the bone blood flow had been preserved. The cause of pain and functional disability was thought to be the results of relatively elevated greater and lesser tuberosities resulting in a bony subacromial impingment. Furthermore, the rotator cuff dysfunction make impingment worse. We performed corrective osteotomy three-and a -half months after the initial accident. With the deltopectral approach, we divided the greater and lesser tuberosities on the lateral to the bicipital groove. Both the greater and lesser tuberosities were osteotomised, lowered and re-attached to the humeral diaphysis. Discomfort during movement diminished and her night pain disappeared, although postoperative rehabilitation proved difficult due to her mental disorder and thus her ROM did not improve. A year and four months after the operation, Xrays showed avascular necrosis of the humeral head. In conclusion, we experienced one case of avascular necrosis of the head after corrective osteotomy on malunited valgus-impacted fracture of the proximal humerus. Because of the high occurrence rate of complications in the treatment of malunion of the proximal humeral fracture, appropriate treatment at an early stage is extremely important.
Trapezius paralysis causes several troubles on the clavicle. The purpose of this paper was to report a case of proximal clavicle fracture with trapezius paralysis, which resisted conservative treatment but showed a good result by fixing the fracture with a tension band wiring and fastening the scapula with an artificial vessel. A 70year-old male got trapezius paralysis after left neck surgery. Two years later, he fell down on his left shoulder and felt pain in his left precordium. The lasting pain brought him to our hospital 1 month later. The left scapula had deviated anterior-downward. X-ray showed a left clavicle fracture and upward projection on the medial fifth. We could reduce it by keeping his chest stretched and his scapula inward. Since he could not tolerate a clavicle band, the operation was carried out 2 months after the injury. We needed to reduce the excessive axial pressure and upward bending force on the fracture, therefore we chose scapula immobilization (based on Dewar's method) with an artificial vessel. We fastened the scapula to C7/T1, T2/3 ligaments with an artificial vessel, and we performed a bone graft and tension band wiring for the fracture. As we observed a good fusion, we pulled the wire out 11 months later. He has had no pain for 2 years and 4 months since the operation.
Three patients in whom irreparable tears of the subscapularis muscles had been treated with a dynamic muscles transfer of the pectoralis major muscle. The purpose of this study was to investigate the clinical results of this operative procedure. Two shoulders were traumatic tears, the other was a dialysis shoulder. All patients had remarkable resting pain in the shoulder. The mean range of motion was 124 degrees of flexion, and 33 degrees of external rotation and internal rotation was from buttock to the fourth lumber vertebra. The mean of JOA score was 55 points. At the time of the operation, all shoulders were found to have an irreparable injury of the subscapularis muscle, so we selected a treatment which was the dynamic muscle transfer of the pectoralis major muscle. In a dialysis shoulder, we added replacement of the humeral head because of the remarkable destruction of the shoulder joint. Recurrence of a tear did not occur in any cases. All had no activity related to pain in the shoulder. The averaged JOA score had increased to 88 points after operation. A dynamic muscle transfer of the pectoralis major muscle was an useful method in patients with irreparable tear of the subscapularis muscle.
The purpose of this study is to report a case which showed the symptoms of brachial plexus palsy after resection of outer end of the clavicle. A 42 years-old, male, had a traumatism in a traffic accident in October 2002. At the beginning, he underwent medical treatment to his head externally caused by the injury. He complained of right shoulder pain and numbness of his right shoulder in the upper limbs after the resection of the outer end of the clavicle. Then, he consulted our clinic. At first, the outer end of the clavicle was dislocated to upper back direction. The range of motion of his right shoulder was slightly limited. Atrophy of the deltoid muscle existed, and the muscle power of deltoid was weak. Numbness existed in the right axillary nerve area and the right forearm. The electromyogram suggested radiculopathy of C5 root. We performed a Dewar method operation to reduce the acromioclavicular joint. In our operation, the nerves of the brachial plexus were distracted under the coracoid process. The nerves were loosened after the reduction of the clavicle. After the operation, the symptoms that were related to the nerves recovered. We performed a Dewar method operation because the symptom appeared to be caused by a disorder of the coracoclavicule mechanism. At the operation, the neurovascular bundle was pulled between the clavicle and the coracoid process. Many cases of the dislocation of the acromioclavicular joint do not present a nerve symptom. We discussed the reasons why the symptoms about the nerves presented themselves in this case. We considered the reasons why in this case brachial plexus palsy, the existed a dysfunction of the scapulothoracic joint before the resection of the outer end of clavicle.
In 1943, Inclan initially proposed tumoral calcinosis. In this study, we reported on a patient with tumoral calcinosis in bilateral shoulders who had not undergone dialysis. A 60-year-old female complained of difficulty in elevating her left shoulder. For 2 years, she had undergone conservative treatment at a local clinic. The symptoms did not subside, and a large shadow suggested calcification; therefore, she consulted our hospital for a detailed examination and treatment. The range of motion in her left shoulder was markedly restricted, and palpation revealed a phyma measuring 4×4 cm on the anterior side of the shoulder. Plain radiography and CT showed marked calcification in the bilateral shoulders. The patient had not undergone dialysis, and the serum levels of Ca, P, and PTH were indicated within normal. Surgery was performed on the left shoulder. The phymalike calcinosis lesion was extirpated through an anterior incision. The pathological findings suggested tumoral calcinosis. After surgery, the range of motion improved, and rehabilitation was achieved, with a good course. In the future, therapeutic strategies for the right shoulder should be selected, and follow-up of the iresidual phyma in the left shoulder should be performed.