The predilection of shoulders with significant anterior-inferior bone deficiency to sustain recurrent dislocation was reported on recently. Burkhart's hypothesis is as follows; the glenoid bare spot is located at the center of a circle defined by the anterior, posterior, and inferior borders of the lower glenoid and then the glenoid bone loss is quantified arthroscopically by using this landmark. In this study, we quantified the glenoid shape to verify the hypothesis. Twenty cadaver shoulders were used to measure the glenoid. Twelve cadavers were men, and 8were women, with an average age of 84 years old (79-89 years old). The soft tissues were stripped except for the labra, which were not included in measurements. The distances of the longitudinal and transverse axis of the glenoid were measured using the caliper. The inferior glenoid was then measured, measuring from the center of the bare spot to the anterior, posterior, and inferior glenoid rims. The distances of the longitudinal and transverse axis of the glenoid were 29.5 mm (range,23.0-35.7 mm) and 21.4 mm (range,15.8-24.9 mm), respectively. A bare spot on all of the 20 cadaver shoulders was found. The distance from the center of the bare spot to the anterior glenoid rim was 11.5 mm (range,8.2-14.4 mm). The distance from the center of the bare spot to the posterior glenoid rim was 11.5 mm (range,8.3-13.4 mm). The distance from the center of the bare spot to the inferior glenoid rim was 12.1 mm (range,9.2-15.0 mm). There was not significant difference among these 3distances. The glenoid bare spot was located at the center of a circle defined by the anterior, posterior, and inferior borders of the lower glenoid. It was suggested that the glenoid bone loss was quantified arthroscopically.
There have been few reports on the motions of the acromioclavicular (AC) joint. The purpose of this study was to analyze the 3D kinematics of the AC joint during arm abduction using 3D MR images obtained by a vertically open MRI. We examined 14 shoulders of 7 healthy volunteers (all men; mean age 23.6 years old) using a vertically open MRI. MR images were obtained in a seated position at 0,30,60,90,120,150 degrees, and the maximum abduction.3D surface models of each bone were created from MR images and the movements of each bone from 0 degree of abduction to other positions were calculated by voxel-based registration. The local coordinate system of the scapula was defined and 3 rotational parameters of the scapular motion relative to the clavicle were expressed by Euler angles according to the recommendation of ISB. In addition, the rotational motions of the AC joint were analyzed using the concept of the screw axis. The scapular motion relative to the clavicle totally showed 15.6 degrees of protraction,21.5 degrees of upward rotation and 22.2 degrees of posterior tilting. Regarding the analysis using the concept of the screw axis, the scapula generally rotated about an axis passing through the insertions of both the AC ligaments and the coracoclavicular ligaments on the coracoid process. The average degree of rotation was 34.9 +/- 8.4 degrees. This is the first report that the AC joint had large degrees of rotation. The AC dislocation clinically is a common injury. The present results will provide surgeons helpful information when they select the surgical treatment for an AC dislocation.
Scapular motion exerts a great influence on shoulder motion. Shoulder motion consists of glenohumeral rhythm and scapulothoracic rhythm and the scapula plays a key role for both rhythms. However, there was no standardized radiographic evaluation for scapular motion because of its complication. This was the starting point of this study and we developed a novel radiogram, “Wing view” for the evaluation of scapular motion. The aim of this study was to evaluate the diagnostic potential of Wing view and to analyse the scapular motion. METHODS: We evaluated 68 shoulders in 34 normal volunteers (27 men and 7 women). The technique of Wing view involves x-ray examination for bilateral scapula and spinal process at the same plane under the upper trunk which is flexed at 90 degrees. Shoulders were postured in three ways: (1) 90 degrees of horizontal abduction, (2) neutral position and (3) maximal horizontal adduction. We measured two parameters by computerized image analyzing software. SS: the angles between the spinal process and medial edge of the scapular, ST: anterior inclination angles of the scapula. We analysed two parameters in three shoulder positions. RESULTS: Wing view radiograms of 31 volunteers were eligible for evaluation. Three volunteers were inadequate for analysis, because of one scoliosis and two posture difficulties. SS in the three shoulder positions were 29.5 ±7.5, 56.2 ±7.1, 58.9 ±5.4 respectively. ST were 36.8 ±8.5, 55.0±6.1, 59.1±5.3 in the same manner. CONCLUSION: We could analyse scapular motion relatively easily by using Wing view. The scapula moves antero-laterally during shoulder movement from 90 degrees of horizontal abduction to neutral position.
We reported on the original method using computed tomography (CT) to measure humeral head retroversion utilizing humeral functional axis at the 29th,30th,31st annual meeting of the Japan Shoulder Society. But we did not evaluate how the humerus positioning affects the measurements of humeral head retroversion using CT. The purpose of this study was to examine the influences of humerus positioning on the measurements of humeral head retroversion using CT. The first series: 10 dry cadaveric humeri, without apparent evidence of degenerative changes of humeral head or previous fracture were examined. The marker made of lead was put on the boundaries of humeral cartilage. The specimens were put on the CT table with lesser tuberosity and anterior surface of the condyles of the elbow down and scanned 1mm interval at the level of humeral head and distal humerus. We adopted two kinds of humeral axis; Simeonides' method (Method S) and Method A of our own device utilizing Nobuhara's anatomical axis. In Method A, we availed the composition of two scans at the level of humeral head: the scan including the center of SSP facet and the scan including the largest diameter of humeral head. We drew the humeral functional axis that the distance from SSP facet to the point on the articular surface was the longest. The cubital axis was drawn as the tangent to the epicondyles. We measured the angle between the humeral head axis and the horizontal plane. Humerus positioning was reproduced by applying methods of MPR (multiple planer reconstruction). We measured the humeral head retroversion angle in 0,5,10° of flexion and extension, and 0,10,20° of adduction and abduction. The second series: we studied 62 shoulders of 31 healthy volunteers ( 16 men and 15 women,21 to 39 years old, mean 29 ± 6 years old). CT was performed with the subjects in supine position with the arm straight and along the body, and the palm fixed under the buttocks. We measured the humeral head retroversion in same fashion to the first series. The mean value of the humeral head retroversion using Method S tended to increase gradually with the increase of the flexion or adduction angle, and tended to decrease with the increase of extension or abduction angle. The measurements using Method A was stable compared with Method S. In Method A, there were no significant differences between 0° and 20° of flexion or 20° of extension and between 0° and 10° of adduction or 10° abduction. The result of this study for healthy volunteers was similar to that for cadaveric specimens, in the Method S, however, the change of humeral head retroversion in position of adduction or abduction tended to be large compared with the result of the first series. On the other hand, Method A was stable regardless of the size of retroversion angle. Why would the measurement value vary by humerus positioning? We made an ellipsoid model made of cork of which the marker made of lead was put on the ellipse which had the largest diameter. We simulated the inclination angle of the humeral head using this model. The model was scanned by CT, and simulated the humerus extension and flexion by changing the direction of roentgen beam. The inclination of the line joining the markers varied depending on the direction of the roentgen beam. I n the simulation of abduction and adduction, however, the line of the marker had not changed. In the first series, adduction and abduction affect the measurement value like flexion and extension. The result using this model is Incomplete to explain the result of the first series. There is a possibility that the axis of the ellipse of the base of the humeral head inclines against the axis of the humeral shaft and this phenomenon affects the measurements of humeral head retroversion
The purpose of this study was to investigate the Bennett lesion using ultrasonography(US). We used US to investigate 42 shoulder joints of 21 baseball players (mean age,22.9 years old) who had a Bennett lesion. Aloka SSD 4000 ultrasonic device was used with a 10.0 MHz linear probe. We took long and short axis views of the posteroinferior glenoid and characterized the anatomical relationship between the Bennett lesion and the surrounding tissues. In all subjects, the posterior fiber of the triceps long head originated from about the 8o'clock position of the glenoid and the Bennett lesion was located very close to the origin of the triceps long head. There was a low echo area in the teres minor above the Bennett lesion which was attributed to inflammation or local edema. 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 remains controversial. In 2004, we studied 25 shoulder joints from 20 cadavers in order to clarify the anatomy of the posteroinferior glenoid and demonstrated that the Bennett lesion coincides with the origin of the triceps long head. The present study used US to confirm these previous results. We consider that the Bennett lesion is more closely associated with the triceps than with the posterior capsule.
The purpose of this study was to analyze relevant factors in recurrent anterior glenohumeral instability associated with a rotator cuff tear. Six cases (7shoulders) of recurrent anterior glenohumeral instability associated with a rotator cuff tear were observed. Simultaneous arthroscopic rotator cuff and Bankart repair was performed on all cases. The cases were 3 males and 3 females, with an averaged age of 50.5 years old. The mean follow-up period was 15 months. We considered their pathology of anterior glenohumeral instability as two types. Young type; Elder type. Three shoulders were Young type (major trauma, a rotator cuff tear at the dislocation and Bankart lesion mainly causes anterior instability). Four shoulders were Elder type (minor trauma, rotator cuff tear before dislocation, capsular tear and M. subscapularis tear at the dislocation and Many factors, such as Bankart lesion, capsular tear and M. subscapularis tear cause anterior instability). Excellent clinical results of simultaneous arthroscopic rotator cuff and Bankart repair were observed.
The recovering process of shoulder strength was investigated in patients who had been treated for a traumatic anterior shoulder instability. The patients were divided into two groups. Arthroscopic group consisted of 20cases that underwent Caspari's transglenoid multiple suture technique, while the open group consisted of 19 cases that underwent Bankart procedure augmented by a coracoid transfer. The average age at surgery was 26 years old in the arthroscopic group, and 29 years old in the open group. The same postoperative regimen was done for all patients. Complete immobilization was maintained for 3 weeks. After that, passive ROM exercises were started, and muscle strengthening exercise were started at 8 weeks. The strength in the following muscles was measured with a hand-dynamometer: the abductor at 45 and 90 degrees and the external and internal rotators at the hanging arm. The measurement was taken three times and averaged. The strength was measured at preoperation and every six months after surgery. The abductor at 90 and the external rotators at 6 months after surgery were significantly less than those at preoperation in arthroscopic group. Then, the abductor at 90 recovered to its preoperative strength at 12 months, while the external rotators recovered at 18 months. On the other hand, the abductors at 45 and 90, and the external rotators at 6months after surgery were significantly less than those at preoperation in the open group. Those strengths recovered to its preoperative strength at 12 months. Regarding to comparison between two groups, both abductors and internal rotators at 6 months in the open group were significantly less than those in the arthroscopic group. However, there were no differences in strengths at 12 months both groups.
A Hill-Sachs lesion greater than 20% of the humeral cartilage is thought to be a surgical indication. However, there have been no anatomical or biomechanical reports. The purpose of this study was to determine the contact between the glenoid and the humeral head to obtain a clue for surgical indication. We used nine freshfrozen cadaveric shoulders (mean,71 years old). The specimen was fixed to a shoulder-positioning device. A 22-N force was applied to the humeral head. The insertion of the supraspinatus tendon, the infraspinatus tendon, and the teres minor tendon was sectioned. Anterior structures such as the glenohumeral ligaments and the subscapularis tendon were preserved. The entire rim of the glenoid was marked on the humeral head using a Kirschner wire with the arm in maximum external rotation and horizontal abduction. This marking was repeated with the arm in 0°,30° and 60° of abduction. The distances from the contact area to the edge of the articular surface of the humeral head and to the footprint on the greater tuberosity were measured by a digital caliper. With an increase in arm elevation, the. glenoid shifted from infero-medial to supero-lateral direction, creating a band-like zone along the rim of the articular humeral cartilage. We named this zone a “glenoid track”. When a Hill-Sachs lesion exceeds the “glenoid track”, there is a risk of engagement and dislocation. The width of the “glenoid track” (0°,30° and 60° of abduction ) was 17.0 ± 6.6 mm,162 ± 62 mm, and 15.8 ± 2.5 mm from the humeral articular cartilage edge and 18.4 ± 2.5 mm from the foot print or 84 ± 14% of the glenoid width. Hill-Sachs lesion which exceeds 84% of the glenoid width has a risk of engagement and dislocation.
A large bony defect of the glenoid or a thinned AIGHL caused by an anterior soft tissue damage in the traumatic anterior instability of the shoulder makes an arthroscopic repair difficult. The purpose of this study was to evaluate the degrees of bony defect and the soft tissue damage quantitatively and to analyze the relation of those degrees to factors, such as the number of dislocations statistically. MRI and 3D-CT images of 33patients were used. The area of the subscapularis muscle on the oblique sagittal plane of T2 weighted MRI at the level of the glenohumeral joint was measured. The area of the anterior-inferior portion of the glenoid on 3DCT image was measured. The degrees of decreased area compared with the contralateral side was calculated. The correlation of the two degrees and between the degrees and the age, the number of dislocations, and the duration were analyzed. The decreased rate of subscapularis area was 12.4% on average, and the decreased rate of glenoid area was 12.6% on average. There was no correlation between these two rates. The rate of glenoid area was correlated to the number of dislocations. No correlation between these two rates indicated the different pathogeny.
Immobilization has been a routine modality after Bankart repair. In 1894, Scripture reported “Cross-education”the ability for exercise of one limb to cause an increase in the strength of the contralateral unexercised limb, however, no report has been in the shoulder. Therefore, the purpose of this study was to examine the effects of a healthy shoulder strength training program on the muscles of the untrained, operated shoulder. Twelve patients after arthroscopic Bankart repair for recurrent dislocation of the shoulder were included. The patients were randomly divided into a control group and a healthy shoulder training group. The training group underwent isokinetic training with Kin Com® (Rehav World, TN, USA) since the day after surgery. Both groups underwent immobilization with a sling of the affected shoulder for three weeks and began a standard program. At the 6 and 12 weeks,6 and 12 months, each participant's shoulder muscle strength was measured. The repeated-measures ANOVA was used to evaluate the data analysis, at a level of 0.05 was considered significant. Both groups reduced peak torque of the operated shoulder compared with preoperative strength after 6 weeks, however, the control group decreased operated shoulder strength of internal rotation and abduction significantly at 6 weeks (p<.05). This study was the first to our knowledge to explore the benefit of a healthy shoulder training program of the operated contralateral shoulder. This study showed that the training group tended to reduce the loss of shoulder strength of the operated shoulder. The most plausible explanations of the crossover benefits are enhancement of the neuromuscular facilitation and undetectable isometric contractions of the untrained limb during strength training. In this manner, we can demonstrate a significant reduction of loss in strength of the muscles around the operated shoulder and better illustrate the crossover benefit.
Recently, arthroscopic Bankart repair has frequently been used as a treatment for anterior instability of the shoulder joints. We have also performed arthroscopic Bankart repair using absorbable suture anchors. We encountered three patients in whom the anchor hole remained and had enlarged on MR images taken three months after surgery. We have used PANALOKTM anchors for arthroscopic Bankart repair since 2000. In an anchor type in which tension is imposed on the suture to lock the anchor hole as the PANALOKTM anchor does, when slight absorption occurs, it is likely to loosen, causing a slight shift of the anchor. Moreover, the mechanical effect may enlarge the anchor hole. In our investigation of MR images, enlargement of the anchor hole was found in three of 28 shoulders (11%). Three months after surgery, a subjective feeling of instability was found in two of three shoulders (67%). Therefore, we concluded that it was necessary to follow -up such cases carefully.
Nontraumatic instability of the shoulder joints revealed several pathological features, such as voluntary dislocation and habitual dislocation, based upon loose shoulder. The purpose of this study was to evaluate the clinical results of nontraumatic instability.44 shoulders of 43 cases (18 males and 25 females) with nontraumatic instability were treated and followed-up for more than 1 year. Their average age was 21.5 years old. The clinical evaluation was performed using the JSS Shoulder Instability Score. At first, we treated these cases conservatively using the brace originally designed to protect the scapular rotation and winging. The indications for an operative treatment were those cases which had performed muscle exercises for more than 1 year and revealed instability, limited direction experienced in daily life and sports disorders. The clinical results improved from 63.1 points to 83.4 points. Recurrence of the symptoms occurred in cases on whom we had performed a shrinkage procedure. The clinical results of nontraumatic shoulder instability were sufficient. The brace originally designed to protect the scapular rotation and winging was effective. The operative indications should be selected prudently.
In the present study, we evaluated the results of treatment in 8 cases in which we elected conservative treatment despite the presence of surgical indications, and we assessed the pros and cons of the indications in 18 cases that we treated surgically. The surgically treated group (S group) consisted of 18 patients: 10 with a 2-part fracture (fracture-dislocation in 1) and 8 with a 3-part fracture (fracture-dislocation in 2). Their ages at the time of surgery ranged from 22 to 76years old (mean: 42.8 years old); and the mean postoperative follow-up period was 3 years and 2 months. There were 8 patients in the conservatively treated group (C group); 4 of them had a 2-part fracture and the other 4had a 3-part fracture. Their ages at the time of the injury ranged from 60 to 85 years old (mean: 77 years old), and the mean follow-up period was 9.5 months. The results of treatment were assessed on the basis of the JOA scores. We also calculated the humeral neck shaft angle and the distance between the tip of the head of the humerus and the plate edge or the greater tuberosity (distance A) on the radiographs, and evaluated their influence on the results. Bone union was achieved in every case. The time required for a bone union to occur in the S group ranged from 13 to 25 weeks (mean: 18 weeks), as opposed to 9 to 16 weeks (mean: 12.4 weeks) in the C group. The mean JOA score in the S group was 83.5, versus 86.7 in the C group. In the radiographic evaluation, the neck shaft angles ranged from 122° to 148° (mean: 134° ) in the S group, as opposed to 120°to 162° (mean: 140.5° ) in the C group, and the distance A ranged from 10 mm to 29 mm (mean: 21 mm) in the S group, versus -5 mm to 32 mm (mean: 6.1 mm) in the C group. No correlations were found between the radiographic evaluation data and the results of treatment in the C group, whereas in the S group a positive correlation was found between distance A and the JOA scores, and results of treatment were significantly better in those patients with a neck shaft angle of 130° or more compared to the other patients with less than 130°. Satisfactory results were obtained by conservative treatment of fractures of the proximal humerus without dislocation in elderly patients even though a high degree of malunion persisted. Selections of surgical treatment for patients who are not very active need to be reconsidered, even in cases of severe displacement.
We investigated the clinical results of displaced proximal humeral fractures treated by Polarus humeral nailTM over 12 months after surgery. Twenty shoulders of 20 patients (1 males, mean age 70 years) underwent intramedullary fixation using Polarus humeral nailTM. Fracture types were 2 parts (6 cases), and 3 parts (14cases) by Neer classification. The trauma mechanism was pedestrian fall for all the patients. In surgery, the deltoid muscle was split and the suprasupinatus tendon was incised about 4 cm longitudinally. The entry hole of the nail was created 1 cm posterior to the bicipital groove with a bone awl. Two or 3 proximal screws were inserted to fix the fracture fragments including the avulsion greater tuberosity fracture (14 cases). The mean follow-up period was 32 months (range,13-58 months) after surgery. Clinical results were assessed by the duration of surgery, amount of bleeding, duration for bone union, complications and JOA scores. The mean duration of surgery was 101 minutes (51-180). The mean amount of bleeding was 117ml (20-300ml). In one case, re-operation with the humeral head prosthesis was necessary 1 week after the initial surgery, because one proximal screw was cut out from the head and the fracture was severely displaced. In other 19 cases, bone union was obtained in mean 2.8 months (2-5 months) after surgery. Proximal screws had to be removed in 3cases because of pain and a granting sensation from backed-out screw. Mean JOA score was 95.6 points (range,83-100 points). Polarus humeral nailTM can be one of the effective options for the treatment of displaced proximal humeral fractures.
We investigated the usefulness and problems of Polarus humeral nails for Neer's 3part fractures of the proximal humerus. We studied 6 patients who were operated on using Polarus humeral nails for Neer's 3part fractures of the proximal humerus. They consisted of 6 females aged from 55 to 90 years old (mean 71). Three cases were B1.1, two cases were B2.1 and a case was B2.2 (AO classification). The follow-up period ranged from 8 to 21 months (mean 14). We investigated the bony union, the postoperative JOA score, and range of motion of the shoulder joint. All the patients who underwent osteosynthesis obtained a bony union, but no osteonecrosis of the humeral head. There was one case with a malunion. The postoperative JOA score was a mean 83.5 pts. The postoperative active range of motion of the shoulder joint was a mean 126 degrees in elevation and a mean 43.3 degrees in external rotation. Postoperative results were good in 5 cases. The operative technique in 3part fractures was more difficult than in 2part fractures. AO classification had some types of fracture in Neer's 3part, and B2.1 type fractures were the most difficult of operative techniques.
The purpose of this study was to evaluate the results of operative or conservative treatments of glenoid rim fracture of the scapula in 10 patients who were treated from 1999 to 2004. Eight were males and 2 were females. The average age of the patients was 42 years old (range,17 to 72 years old). All the cases had an anterior dislocation of the shoulder. According to Idebergi s classification system,6 cases were type Ib and 4cases were type Ib+II. The bone fragment size was evaluated by computed tomography. Six cases with fractures involves 25 % or more of the anterior glenoid rim were treated operatively and 4 cases with those involves less than 25% of the anterior glenoid rim were treated conservatively. In cases treated surgically, the delto-pectoral approach was used. As to the internal fixation method, a screw was used in 5 cases and a screw and suture anchor was used in 1 case. Clinical results of both treatments were evaluated according to the Japan Orthopaedic Association (JOA) scoring system. The average follow up period was 2.7years (range,5 months to 5.8 years). The average JOA score with operative treatment was 92 points (87 to 97 points) and that with conservative treatment was 89 points (75 to 97 points). The results were almost satisfactory except in one young patient with general joint laxity who complained of some shoulder joint instability after conservative treatment. It seems reasonable to conclude that operative treatment should be indicated when the fragment involves 25% or more of the anterior glenoid rim, but it seems to need reconsideration operative treatment indication when patients are young and associated with general joint laxity even if the fragment involves less than 25% of the anterior glenoid rim.
The purpose of this study was to evaluate the clinical results following non-operative treatment of middle-third fractures of the clavicle. We evaluated 67 middle-third fractures of the clavicle over 10 years of age. There were 42 men and 25 women, whose mean age at the time of injury was 40.1 years old (range,10 to 98) and mean follow-up period was 6.3 months (range,1-36). The fracture was caused by a traffic accident in 24 patients and by sports injury in 13 patients. Type 2A1 fracture (Robinson's classification) had 16 cases, type 2A2 had 8, type 2B1 had 37, and type 2B2 had 6. All patients were treated by figure-of-eight braces. Fracture-union was obtained radiologically in 63 patients (94.0%). The average period for fracture union was 6.0 weeks in type 2A1,5.2 weeks in type 2A2,10.7 weeks in type 2B1 and 11.4 weeks in type 2B2. We found a statistical association of the average period for fracture union between type 2A2 and type 2B fractures (p<0.05). Nonunion was seen in 4 cases of type 2B1 fracture, in which shortenings of 20mm or more were seen on their initial radiographs. We found that age in cases over 45 years old was associated with a developed non-union (p<0.05). The average period for fracture union of over 45 year-old-patients with type 2B clavicle fracture was 13.1 weeks. Two of them were treated surgically. The overall results of non-operative treatment of middle-third clavicle fractures were satisfactory except for type 2B cases with shortening of more than 20 mm. This study achieved a 94.0% of union rate in middle third clavicle fractures treated non-operatively. Risk factors of a non-union was considered in over 45 year- old-patients with a type 2B clavicle fracture, and those with no callus formation in 13 weeks.
The purpose of this study was to determine the relationship between retraction of rotator cuff tear and the position of the suprascapular nerve. In 33 shoulders of 27 patients (mean age 61 years old) with and 10 shoulders of 10 patients (mean age 47 years old) without full-thickness tears of the supraspinatus tendon, we measured the position of the suprasucapular nerve on Ti-weighted coronal oblique images and the tear length on T2weighted coronal oblique images. We defined the retraction length as the longest distance from the lateral margin of the superior facet of the greater tuberosity and the torn edge of the tendon and the position of suprascapular nerve as the distance from the glenoid surface to the suprasucapular nerve using 3 images (anterior, middle, and posterior images of the supraspinous fossa). These data were evaluated using Pearson's correlation coefficient and the Mann-Whitney test. The distance from the glenoid surface to the suprascapular nerve was 24.0 ±3.7 mm in the anterior slice,19.7±2.6 mm in the middle slice and 14.3±3.4 mm in the posterior slice in the control group, whereas 25.1±3.9mm,19.9 ±3.8 mm and 13.5±2.9 mm respectively in the tear group. There was no significant difference between these groups. The correlation coefficient between the tear length and position of the suprascapular nerve was 0.50 (p<0.01) in the anterior slice,0.27 (p>0.05) in the middle slice, and 0.31 (p<0.05) in the posterior slice, but there was no significant difference among these slices. We concluded that retraction of torn tendon affects more displacement of motor branches than the trunk of the suprascapular nerve. The increased tautness in motor branches may place the nerve at risk of injury.
Increased signal intensity on MRI is considered to be not only disruption but degeneration of the rotator cuff tendon. Histologic degeneration is reported to be more severe than abnormalities seen either grossly or on MRI. The purpose of this study was to determine the histopathologic correlates of alteration in the tendon with incomplete rotator cuff tears at open MRI. Forty shoulders with incomplete rotator cuff tears (8 bursal side: BST and 32 articular side tears: AST) found surgically underwent open MRI in the coronal oblique plane at 0.2T with Ti and TT-weighted sequences. The insertional area of the tendon corresponding to sites of MRI alteration were then examined histologically. The signal intensity in cases with AST was higher in deep layers than in superficial layers (p<0.01). Also, those with BST tended to be higher in superficial layers, compared to deep layers, but the difference was not significant. Areas of increased signal intensity on TT-weighted images corresponded to histologic changes consistent with tendon degeneration, especially, thinning and disorientation of collagen fibers, and myxoid degeneration (p<0.01). The cases with dystrophic calcification demonstrated higher signal intensity on MRI. Increased signal intensity in the osteotendinous junction at MRI corresponded to the destruction of four layers histologically. No correlation was observed between the subacromial bursal invasion or replacement in tendon tissues and signal patterns at MRI. In the superficial layer, loss of subacromial-subdeltoid fat plane correlated of severe degenerative findings of tendon tissues histologically. Recognition of increased signal intensity in the tendon with incomplete rotator cuff tears and osteotendinous junction at MRI was helpful for demonstrating the extent of tendon degeneration and estimating the quality of the tendon tissues, preoperatively.
The purpose of this study was to examine indication of conservative treatment for partial thickness tears of the rotator cuff, we reviewed the medical history and arthrographic findings of the cases that had conservative treatment for partial thickness joint side tears of the rotator cuff. We studied the 71 shoulders of 71 patients who could be diagnosed as joint side tear of the rotator cuff by shoulder arthrogram. Arthrography was repeated 6 months after initial visit and treatment We compared the arthrographic findings of the initial visit with those of six months after. Then we defined the case when the tear size was reduced as improvement, the case when the tear size was not changed as unchanging, the case when the tear size was extended as deterioration. We divided the cases into two groups; the improvement group (21 shoulders) and the unchanging+deterioration group (50 shoulders). The differences between the two groups were tested for statistical significance about age, duration from onset of symptom to initial visit, sexuality, presence of trauma, presence of contracture, the maximum dimension of tear (ratio of humeral head) and location of tear.21 cases of the 71 cases had improved. Cases with a partial thickness tear at SSP had deteriorated significantly compared with ISP (p <0.05). In cases with a partial thickness tear at ISP, the smaller maximum dimension of cuff tear at initial visit, the more the condition had significantly improved.30% of the partial thickness tears improved during conservative treatment for six months. Though conservative treatment was not approximately effective for partial thickness tears at SSP, conservative treatment was effective for the smaller maximum dimension of a partial thickness tear at ISP.
The purpose of this study was to clarify the clinical outcomes and problems of arthroscopic rotator cuff repair (ARCR) in patients 65-years of age and older. We evaluated the clinical results and repair integrity using MRI in 42 patients with ARCR (18 men and 24 women, mean age at the time of surgery 70.3 years old). Preoperatively and at the time of follow-up (at a mean of 19.1 months), the patients were assessed with Japanese Orthopaedic Association (JOA) shoulder scores. Subjective symptoms and JOA shoulder scores of all patients improved after surgery (p<0.0001). The average postoperative JOA shoulder score at 12 months after surgery improved to 96.5 (vs.51.5 preoperatively) points. An average postoperative abduction range improved to 170°(preoperatively 94° ), and external rotation improved to 61° (preoperatively 20° ). Postoperative complications including CRPS, shoulder stiffness and anchor failure were not seen in this series. No differences were observed in clinical outcomes compared with 24 shoulders in patients 65-years of age and younger. MRI examinations 6months postoperatively showed high intensity in the repaired cuff in 9 of 18 shoulders that had had large and massive tears, whereas small and medium tears presented good repair integrity in 88% (21 of 24 shoulders).
The purpose of this study was to evaluate the clinical results after arthroscopic rotator cuff repair (ARCR) for rotator cuff tears. We evaluated 25 patients (19 males and 6 females) who had 26 shoulders treated for a rotator cuff tear, using the ARCR, from February 2003 and were consequently followed-up for more than 6 months postoperatively. The affected shoulder was on the right side in 12 patients and on the left side in 14 patients. The average age at operation was 58.2 years old (42 to 78 years old); the mean pre-operation period was 9.2months (1 to 60 months); and the mean follow-up period was 11.9 months (6 to 25 months). We arthroscopically performed subacromial decompression and sutured the torn cuff to the greater tuberosity using suture one or more anchors. 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 six shoulders, small in nine, medium in three, large in seven, and massive in one. According to the JOA score, the average total score increased from 61.9 points to 92.9 points. The average scores of pain, function, and motion improved from 8.8 to 26.0 points, from 12.5 to 19.5 points, and from 22.8 to 27.5 points, respectively. We evaluated the shoulder abduction muscle strength. The average strength increased from 2.97±2.56kg to 523±2.35kg. We also evaluated the postoperative MRIs. Postoperative MRI showed 22.7% of re-torn cuff. The clinical outcome of the ARCR was almost satisfactory, but patients with large and massive tears tend to re-tear.
Mini-open rotator cuff repair has been developed with advances in arthroscopic techniques and it has been used successfully to treat rotator cuff tears. However, there is little known about the postoperative accurate second look evaluation for a mini-open rotator cuff repair. The aim of this study was to evaluate mini-open rotator cuff repair by second look arthroscopy and to analyze the correlation between the integrity of the repaired rotator cuff and clinical results. We performed a second look arthroscopy on 12 patients who had undergone a mini-open rotator cuff repair for full-thickness rotator cuff tears. The average follow-up after a mini-open rotator cuff repair was 19.5 months. The second look evaluation was composed of 6 different items: hypertrophy of the intra-articular synovial tissue, hypertrophy of the intra-bursal synovial tissue, articular side integrity at the repaired rotator cuff, bursal side integrity at the repaired rotator cuff, bursal tissue adhesion and appearance of coraco-acromial arch. Clinical results were evaluated using the Japanese Orthopaedic Association shoulder scoring system (JOA score). A full-thickness tear was remained in three cases whose JOA score was less than 90 points. We could not observe a full-thickness tear in nine cases whose JOA score was more than 90 points; an articular side partial thickness tear was observed in two cases and a bursal side partial thickness tear was observed in one case. Three cases of synovial tissue hypertrophy, four cases of bursal tissue adhesion and twelve cases of newly formed coraco-acromial ligaments were recognized. There were correlations between the remaining full-thickness rotator cuff tears and the clinical results. Bursal tissue adhesion might be a worry after a mini-open rotator cuff repair.
A rotator cuff tear with the long head of the biceps (LHB) changing in form is experienced frequently. However, the factors which induced the lesion have been little known. This study investigated the characteristics of the rotator cuff tears with the LHB changing in form.178 consecutive shoulders in 175 patients who underwent rotator cuff repair were studied retrospectively. Out of these shoulders, LHB changing in form was identified in 48 shoulders in 48 patients (LHB group). However, the rotator cuff tears with an LHB rupture were excluded from this study. The age of the patients ranged from 33 to 84 (mean 61.4) years.31 patients were men and 17were women.127 shoulders of 130 patients who had rotator cuff tears without the LHB changing in form were defined as control group. Medical histories and operative findings were compared between the LHB and control groups. There was no significant difference between the LHB and control groups in age or gender. The traumatic presence in the LHB group was significantly more than that in the control group (p<0.05). The duration from injury to operation in the LHB group was significantly shorter than that in the control group (p<0.05). The size of the rotator cuff tear in the LHB group was significantly larger than that in the control group (p<0.0001). Cases with a subscapularis tear in the LHB group were significantly more than those in the control group (p<0.0001). A rotator cuff tears with the LHB changing in form had an acute clinical course of symptoms caused by trauma and involved many cases with a large size of rotator cuff tear and/or with a subscapularis tear.
Atrophy of the infraspinatus(ISP) is one of the most common findings in rotator cuff tears. The purpose of this study was to investigate the relationship between the thickness of ISP and the location in the rotator cuff tear, and between the shoulder external rotational muscle strength (ERMS) and the location in the rotator cuff tear. We examined the thickness of ISP and ERMS of both shoulders in 30 healthy volunteers. We found out the statistical differences for the thickness of ISP between the non-dominant side and dominant side.30 patients with a rotator cuff tear in the dominant side were enrolled in this study. The patients were grouped according to the location of the tear with MRI. Typel (10 cases) had isolated supraspinatus(SSP) tears. Type2 (13 cases) involved SSP-ISP tears. Type3 (7cases) involved ISP tears. The muscle strength was measured with a hand-held dynamometer(MICRO FET): ISP-test at hanging arm, ER II -test at 90 degrees abduction. The thickness of ISP was measured with an ultrasonographic device at rest and on active. The point of the measurement was medial 1/4and 3cm inferior from the scapula's spine. The rates of affected (dominant) / unaffected in ISP-test were 103.2%: volunteers,88.4%(p<0.05): typel,80.0%(p<0.01): type2 and 63.3%(p<0.01): type3. The rates in ER 11 -test were 101.1%: volunteers,88.1%(N. S): typel,68.9%(p<0.05): type2 and 55.7%(p<0.01): type3. The rates in thickness of ISP were 113.9% at rest; 1112% on active: volunteers,110.5%(N. S) at rest; 101.3%(N. S) on active: typel,98.8%(N. S) at rest; 89.7%( p<0.05) on active: type2,85.7%(p<0.05) at rest; 86.4%(p<0.05) on active: type3. We concluded that the cuff tear became enlarged from the SSP to the ISP, if atrophy of the ISP was found.
Various attempts have been made to reattach the torn tendon edge to the anatomical insertion site. However, if a tear is too large to reattach the tendon to the anatomical site, the torn edges are fixed to the bony trough created medial to the original insertion site. It is clinically important to know how far medially we can shift the reattachment site. Ten fresh frozen cadaveric shoulders (mean, sixty- eight years old) were used. The specimen was mounted to a custom-made testing device with a 22-N joint compressive load. Medial shift was simulated by the placement of suture anchors along the lines 3,10, and 17 mm medial to the greater tuberosity. The ranges of glenohumeral motion (abduction, external rotation at 0 and 60° of abduction, and internal rotation at 0 and 60° of abduction) were measured before and after medial shift. The range of motion was measured by goniometer under constant torque application. Medial shift (3,10, and 17 mm) reduced the range of abduction, compared with that of the intact shoulder, by 4 ± 5°,17 ± 10°, and 31 ± 110, external rotation by 8 ± 5°,11 ± 6°, and 18 ± 7°, external rotation at 60° of abduction by 8 ± 5°,15 ± 10°, and 18 ± 8°, internal rotation by 4 ± 4°,7 ± 7°, and 11 ± 7°, and internal rotation at 60° of abduction by 5 ± 5°,7 ± 5°, and 9 ± 7°. Joint motion decreased significantly in almost all directions after a medial shift of 10 mm and 17 mm. Significant restriction of joint motion occurs after a cuff repair when a bony trough is created more than 10 mm medial from the foot print.
Postoperative evaluations of rotator cuff repair have been performed using only objective data, and subjective evaluations, such as patient satisfaction have not been regarded as important. Our report focused on the postoperative patient satisfaction and examines factors which affect this. We performed the McLaughlin's procedure on patients with rotator cuff tears, targeting 109 shoulders 01 109 cases followed-up more than 1year. A self evaluation was performed by the patients of their satisfaction with 100 points being a perfect score one year after the operation. Cases were classified into 43 shoulders in the satisfied group (100 points) and 66shoulders in the unsatisfied group (under 100 points). We compared the 2 groups in terms of age, the period from onset to surgery, UCLA scores 1 year after surgery, as well as range of motion and muscle strength 1year after surgery. Then, we compared the patint satisfaction score in terms of gender, dominant side, history of injury, size and region of the tears, findings of MR images 1 year after surgery as well as findings of postoperative roentgenograms. A significant difference in pain in the UCLA score was revealed between the satisfied group and unsatisfied group. All the cases in the satisfied group had no pain 1 year after surgery, and pain persisted only in the unsatisfied group. However, only a few patients complained of strong pain, and there were many patients who complained of dull pain after manual labor. In addition, cases involving a rotator interval tear and/or subscapular tendon tear had a significantly lower satisfaction than other cases. Tears of the rotator interval and/or the subscapular tendon and pain persisting 1 year after surgery may be factors affecting patient satisfaction.
Treatment of the long head biceps (LHB) tendon concurrent with that for a rotator cuff tear remains controversial. We attempted to determine whether an LHB tenodesis procedure improved the clinical outcome in patients treated for a rotator cuff tear. Ninety-two shoulders in 88 patients with a complete cuff tear came to us for surgical treatment. We excluded those with intact LHB tendons, a complete rupture of the LHB tendon, an irreparable rotator cuff tear, and who had undergone previous surgery from the present study, thus 42shoulders were studied prospectively. The patients were randomly divided into the cuff repair with LHB tenodesis (group T, n=24) and without LHB tenodesis (group N, n=18) groups. All patients underwent an open subacromial decompression and rotator cuff repair using the McLaughlin procedure, with a biceps tenodesis technique with an interference screw placed into the bone socket of the bicipital groove added to the procedure for Group T. Clinical features and surgical results of the 2 groups were evaluated. The average total JOA scores prior to the operation in groups T and N were 58.3 and 65.3 points, respectively, while post-operational JOA scores were 88.5 and 86.8 points, respectively. The improved pain score for group T was significantly higher than that for group N, whereas the improved shoulder function scores and improved range of motion scores were not significantly different. In conclusion, addition of an LHB tenodesis procedure at the time of rotator cuff restoration tended to improve post-operative pain and provided satisfactory results.
Since February 2000, arthroscopic rotator cuff repairs have been performed. We evaluated 73 shoulders of 75patients followed-up for more than 6 months. The average age at the operation was 64 years old. There were 64full-thickness tears. Small and medium tears were observed in 47 shoulders. Large and massive tears were recognized in 17 shoulders. There were 11 partial thickness tears,6 bursal side and 5 joint side tears. We used anchors in 74 shoulders. Anchor placement was a single row in all shoulders. In 4 shoulders of large and massive tears, partial cuff repairs were performed. In 2 shoulders of massive tears, arthroscopic tensor fascia lata grafts were done. We evaluated the results using the Japanese Orthopaedic Association Shoulder score. JOA score improved significantly. Excellent and good results were obtained in 91 %. In full-thickness tears, small and massive tears had better results than large and massive tears significantly. In partial-thickness tears, bursal side tears had better results compared with joint side tears. About 3 months post-operative MRI T2findings were evaluated by Sugaya's classification. In type 1,2,3, cuff continuity was preserved. Type 4 was minor cuff discontinuity. Type 5 was major cuff discontinuity. Type 1,2,3 were recognized in 66% and type 4and 5 were observed in 34%. In post-operative JOA score, type 1,2,3 had better results than type 4 and 5significantly. Type 4 and 5 were observed in 28% of small and medium tears, in 65% of large and massive tears and 9% of partial thickness tears. There were many problems in large and massive tears. Tendon retraction, tendon substance loss, tendon quality, muscle contraction, muscle quality. We could not resolve several problems surgically. The best indication was for small to medium tears and partial-thickness tears. Good indication was for large to massive tears.
The present study was undertaken to elucidate the specificity of the new test for detecting the rotator interval tears. The test named Downward Distraction Arm at Side (DDAS) test was performed as follows: The examiner stands at the postero-lateral side of the patient. The examiner holds the elbow of the patient's suspended arm with his hand of the same side (ie. the patient's right elbow with the examiner's right hand) to control the rotation of the shoulder. Then, the affected arm is distracted downward quickly either in an internally rotated or externally rotated position. The test is positive if the patient felt an apprehension of the shoulder dislocation with various degrees of pain only in the externally rotated position. Fifteen patients with rotator interval tears (11 males and 4 females), aged from 16 to 50 years old (average 27) were examined preoperatively. There were 6 cases with inferior instabilities and 2 cases with anterior apprehensions. A rotator interval resection and sutures were performed in 13 cases, while the resection and patch grafting was done in 2 cases. All the cases obtained more than 94 points of JOA score postoperatively. The diagnosis was confirmed by a single contrast arthrography and arthroscopy. The DDAS test was positive in 12 patients. Three cases with a negative DDAS test were 38 years of age or more and all had negative inferior instabilities. We concluded that a DDAS test is useful for detecting rotator interval tears with a sensitivity of 80%.
The purpose of this study was to report, on 3cases of septic arthritis of the shoulder joint using antibiotic loaded acryl cement. We reviewed three patients with septic arthritis of the shoulder joint who had had operative treatment with antibiotic loaded acryl cement beads and rods from 2003 to 2004. They consisted of 2 males and 1 female with a mean age was 67.7 years old (range 59-73). Two cases had an underlying disease, the other case had an injection before the symptoms had developed. Streptococcus aureus was cultured in 2 cases and streptococcus agalactiae was cultured in 1 case. All patients were treated with antibiotic loaded acryl cement (antibiotic 2 or 3g / cement 40g) beads and rods to fill up the dead cavity caused by synovectomy of the shoulder joint and resection of the humeral head. After the infections had been resolved, a second operation was perfomed on the humeral head prosthetic replacement using antibiotic loaded acryl cement (antibiotic 1 or 2g / cement 40g). In all the cases infections were resolved after treatment using antibiotic loaded cement. A case without a cuff tear got good range of motion of the shoulder after hemi-arthroplasty. We treated with resection of antibiotic loaded acryl cement in three cases of refractory septic arthoritis of the shoulder. In all the cases, the CRP was negative. We believe that this method is useful treatment of refractory septic arthoritis of the shoulder.
The purpose of this study was to examine the clinical results of arthroscopic stabilization for atraumatic shoulder instability. We retrospectively analyzed 44 shoulders of 42 patients who had been operated for atraumatic shoulder instability. The mean age at operation was 23.0 years old and the mean follow-up period was 25.5 months. We evaluated the direction and degree of instability by examination both in the awake condition and under anesthesia, and performed arthroscopic stabilization using some procedures, including thermal capsular shrinkage, labral repair, plication of the capsule, rotator interval closure and so on. With respect to the direction of instability, we classified atraumatic instability into four types: anterosuperior instability (18 shoulders), anteroinferior (11 shoulders), posterior (7 shoulders), and multidirectional (8 shoulders). The clinical results were assessed by JSS Shoulder Instability Score, recurrent ratio and return to sports participation. The average JSS Shoulder Instability Score after the operation was 89.0 points. The score of shoulders with anterosuperior instability improved from 68.9 to 90.7, anteroinferior from 65.8 to 93.2, posterior from 65.1 to 88.6, and multidirectional from 55.9 to 82.4. Seven shoulders(18.4%) had recurrent instability. A return to sports participation was noted in 92% of 25 patients. The postoperative JSS Shoulder Instaility Score was lower in patients with posterior or multidirectional instability than anterosuperior or anteroinferior one. Of 7 shoulders with recurrent instability, six were treated by thermal capsular shrinkage. Thermal capsular shrinkage was suggested to be an unreliable procedure.
Twenty cadveric shoulders were studied to make holes for suture anchors on the postero-superior glenoid rim. At the point of lateral margin and anterior third point of the acromion length, when a spinal needle is inserted 18 degrees anterior tilt to the plane including the anterior acromial tip, the superior angle and the inferior angle of the scapula, and when it is inserted 28 degree caudal tilt on the scapular plain, the needle can reach to 12o'clock point of the glenoid through the rotator cuff. The distance from the insertion to the glenoid was 30mm.7 shoulders with Type II SLAP lesion were sutured on results of cadveric study. They were 7 male and their average age was 31 year old.18 gauge spinal needle was inserted according to the study, and this portal was enlarged with the step cannulation system.6mm diameter of a cannula was inserted into the joint through the cuff, and mobilization of the labrum, drilling and insertion of suture anchor to the glenoid were performed. Additional Bankart repair was performed to the recurrent shoulder dislocation. Minimal follow-up period was 12 months(ave,14). At follow-up period, there were statistically significant ranges of motion between the affected and the unaffected sides. A baseball pitcher who had been affected on the dominant shoulder returned to original position at 6 months after surgery. One patient re-dislocated his shoulder at 4 months after surgery, falling on the affected side while snowboarding. The remaining 5 patients did not complain of disability or apprehension, or play recreational sports. We obtained satisfied clinical results of Type II SLAP lesion repair based on cadveric study, which was easy to make a hole and to insert suture anchors on the postero-superior glenoid.
The aim of this study is to reveal ROM at the glenohumeral joint of young baseball players. [Materials and Methods] We selected 117 young baseball players without current shoulder symptoms and history of previous injuries of the shoulders. Players ranged in age from 9 to 15 years (average,12 years). Their playing experience ranged from 5 months to nine years, with a mean of 4.2 years. Range of motion of the shoulder (flexion, abduction, external and internal rotation at 90° of abduction) was measured in all players. Computed tomography was performed to measure the retroversion of the humeral head in 15 of 117 players. [Results]Less flexion, greater external rotation and significant less internal rotation were found in the pitching side (PS)compared with the non-pitching side (NPS) (p < 0.05). Loss of internal rotation in PS was observed in 83.3% of players, with an average loss of 20.7°. There was no correlation between laterality in internal rotation and years of play, and age. Retroversion of the humeral head in 15 players was greater in PS compared with in NPS. Their internal rotation averaged 14. T in PS and 41° in NPS. Laterality in internal rotation improved on rehabilitation; with an average of 20.7 to 9. T in 117 players, with an average of 26.3° to 11.3° in 15 players. [Discussion] Increased external rotation and decreased internal rotation have been well observed in high-level overhead-pitching athletes. Our study demonstrated the same trend was observed in the earlier formative years of a player's career. The implication of this altered arc of motion may be due to tightening of the posterior soft-tissue structures leaded by repetitive exercise.
The purpose of this study was to show that the physical change in the growing period has a great influence on the trunk rotation in throwing athletes using the trunk rotation test (TR test). We studied 89 baseball players consulting our clinics for a medical check-up with a mean age of 14.7 years old (range,7-23 years old). Our cases were classified into the following four groups: the primary school group consisting of 22 cases (primary group; mean,10.1 years old), the junior high school group consisting of 27 cases (junior-high group; mean,13.6 years old), the high school group consisting of 24 cases (high group; mean,16.8 years old), and the adult group consisting 16 cases (mean,19.8 years old). We examined the trunk rotation with TR test presented by Fujii in the 31st JSS meeting. We considered the test positive when the rotation angle of the throwing side was clearly lower than that of the non-throwing side. We compared the positive ratio of the TR test among 4 groups statistically with chi-square tests. In the primary group, there was no positive case in the 22 players. In the junior-high group 3 cases of 27 were positive (11.1%), in the high group 8 cases of 24 were positive (33.3%), and in the adult group 7 cases of 16 were positive (43.8%). Especially, in the primary and junior-high groups before and during the growing period only 3 of 49 cases were positive (6.1%), while in high and adult groups after the growing period 15 of the 40 cases were positive (37.5%) (P<0.05). This study showed that in the throwing athletes the trunk rotation to the throwing side tended to be restricted with advancing ages, and the growing period had a great effect on the restriction of the trunk rotation.
The purpose of this study was to investigate whether the posterior capsular tightness influence the anterior instability and the pathogenesis of several pathological lesions in throwing injury of the shoulder. All 54patients, who failed conservative treatment and underwent arthroscopic surgery because of a throwing shoulder injury between 2002 and 2004 were included in this study. Among them,38 shoulders were regarded as positive posterior capsular tightness, according to the presence of internal rotation deficit and stiffness and loss of elasticity of PBIGHL on arthroscopic finding. Anterior joint instability and frequency and site of SLAP lesion and rotator cuff tear were investigated regarding the relationship with posterior capsular tightness. Anterior joint instability was defined as positive, when anterior joint laxity in an affected shoulder was larger than that in an unaffected shoulder on examination under general anesthesia As results, anterior instability in the tightness group was seen in 37% at 30 degree abduction and in 47% at 90 degree abduction, and their frequencies were higher than those in the non-tightness group (31% and 25%, respectively). While frequency of SLAP lesion was 29 % in the tightness group and 44% in the non-tightness group, the presence of anterior subtype was solely seen in the tightness group. While there was no difference in the frequency of rotator cuff tear, the tear in the anterior aspect of the supraspinatus tendon was more frequently seen in the tightness group (62% and 40%, respectively). In conclusion, as there was a characteristic site in SLAP lesion and rotator cuff tear, the posterior capsular tightness in throwing shoulder was suggested to be a possible factor to induce the occurrence of several pathological lesions relating to the anterior translation force.
A bony Bankart lesion is the osteochondral defect including insertion of the glenohumeral ligament. For the reconstruction of that lesion with an artificial bone substitute, biological healing of the ligament in artificial bone is required. In the current study, we tried to reconstruct bone defects including insertion of the tendon by the tissue engineering technique. Interconnected porous calcium hydroxyapatite ceramics (IP-CHA) was used as a scaffold and cultured mesenchymal stem cell (MSC) was used as a cell source. Cultured MSC was subcultured in IP-CHA. Then, the tendon and. IP-CHA with MSC complex was implanted in the bone defect of a rabbit knee joint [MSC(+) group]. For comparison, the complex without MSC was implanted in the contralateral knee [MSC() group]. Histological findings of the interface between tendon and IP-CHA were almost the same in both groups 3 weeks after operation. However,6 weeks after the operation, more abundant bone formation around the tendon was obtained in the MSC(+) group. The direct apposition of the tendon to bone in the pores and the collagen continuity of the tendon to fibrous tissue in the pores were observed. In quantitative analysis, the area of bone around the tendon in MSC(+) group was significantly larger than that in MSC(-) group 6 weeks after the operation. In the biomechanical evaluation, the maximum failure load of the tendon insertion in the MSC(+)group was significantly higher than that in the MSC(-) group. The histological and biomechanical results revealed MSC cultured in IP-CHA could improve the tendon healing in IP-CHA.
We reported on a pediatric case of post-traumatic osteolysis of the distal clavicle, which has not previously been reported. A seven-year-old boy had a Nuss operation (insertion of convex steel bars under the sternum) for the correction of pectus excavatum. After two years, he had revision surgery because of unsatisfactory results. One week later, he had had an uncomfortable feeling around his right clavicle and it developed into pain with swelling. Six months after the second surgery, we observed osteolysis of the right distal clavicle on a plain radiograph. A bone scan showed hot spots not only in the same region but also in the right sternoclavicular joint. Spontaneous healing of the osteolysis began to be seen on plain radiographs 9 months after the surgery and it was completed at 2 years after surgery. We supposed that an acute anterior shift of the sternum due to Nuss operation affected the acromioclavicular joint as a trauma changing the alignment of the joint and the osteolysis of the distal clavicle arose from this trauma. We retrospectively reviewed the plain chest radiographs including clavicles of 19 children who had Nuss operation but we did not find any lesions. Post traumatic osteolysis of the distal clavicle in children has not previously been reported on and the spontaneous radiological healing of this disease has not been reported on even in adults. This case proposed that we use the conservative treatment for osteolysis of the distal clavicle in children.