The aim of this study was to identify the features of isokinetic shoulder and trunk muscle strength of volleyball attackers with shoulder problems and to compare them with those of baseball pitchers.18 competitive high school volleyball attackers and 16 competitive high school baseball pitchers were studied.6 of the attackers and 7 of the pitchers were suffering from shoulder pain but the other players had no history of shoulder pain. The tests were conducted using a Biodex system 3 multi-joint dynamometer. The shoulders were tested for their flexion and extension muscle strength on the scapula plane and trunk muscle strength were tested for their flexion, extension and torso-rotational strengths. The results were compared between the normal group (N-G)and the shoulder injured group (S-G) and also between the attackers and the pitchers. We observed weakness of shoulder flexion strength in S-G of both athletes and the flexion to extension muscle strength ratio was significantly lower in S-G of the attackers. We also noticed the decline of trunk torso rotation to shoulder extension muscle strength ratio in the same group. In comparisons between the attackers and pitchers of N-G, trunk flexion to extension muscle strength ratio of attackers was significantly higher. The reason of the above results, we assumed that the force created from lower extremities was used for jumping in volleyball, while in baseball, it is used for pitching. We also considered that force required for spiking is created from the trunk in volleyball. Characteristics of shoulder muscle strength as dynamic stabilizer are similar in both volleyball and baseball. Appropriate proximal kinetic chain rehabilitation for the leg, hip and trunk should be selected in accordance with the characteristics of sports activities to prevent shoulder injuries. Especially for volleyball attackers, trunk muscle training is a prerequisite to prevent shoulder injuries.

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The distribution of mineralization of subchondral bone plate (DMSB) by CT-osteoabsorptiometry (CTO) reflects the stress distribution of joint surface. We analyzed the stress distribution by CTO in throwing shoulders, anterior instability, and rotator cuff injury and investigated the results about the disease singularity.370 shoulders, including 44 shoulders in the throwing shoulder group (TS),66 shoulders in the anterior instability group (Al),75 shoulders in the rotator cuff injury group (RC), and 185 normal shoulders were evaluated in this study. Three dimensionally reconstructed computed tomogram (3DCT) and DMSB were filmed in all shoulders.
Glenoid was divided into 13 areas: 12 areas every one hour and in the center area, and the value of each area was classified into 4 grades. All the glenoids had high dense areas in the antero-superior position of rotator interval. There was significantly high distribution of subchondral bone plate areas in the antero-superior and posterior position in the TS group. There were high dense areas in the antero-inferior position compared with the other low dense area in Al group. There was no specific characteristic in the RC group compared with the control group in the elder age. High distribution of subchondral bone dense concentration in the antero-superior area in every group showed that the stress always concentrated at the rotator interval. Entirely high dense concentration in TS was reflected by high activity, and especially high dense in the antero-superior and posterior position was reflected by occult humeral head migration during throwing. Entirely low dense concentration in Al was reflected by low activity from apprehension of shoulder dislocation and high dense in the antero-inferior position was reflected by humeral head instability in the direction. The pattern in RC caused upward migration of the humeral head by functional disorder of rotator cuff from aging.

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The purpose of this study was to determine the accuracy of MR arthrography (MRA) in the classification of SLAP lesions. We investigated 24 shoulders with arthroscopically proven SLAP lesions of the shoulder. The average age was 29 years old (16-60 years old) and all cases were male. MR arthrography (MRA) was performed before arthroscopic operation in all cases. Based on the Snyder's classification, we defined the diagnostic criteria for a classification of SLAP lesion on MRA. Sensitivities, specificities and accuracies between the classification on MRA and arthroscopic findings were calculated. In MRA,8 shoulders were diagnosed as type I,15 type II and 1 type IV. In arthroscopic findings,3 of 8 shoulders classified as type I in MRA were type II, and 5 of 15 shoulders classified as type II in MRA were type I. One type IV case was assessed correctly in MRA. MRA showed a sensitivity of 50 %, a specificity of 79 % and an accuracy of 67 %in type I, and a sensitivity of 77 %, a specificity of 55 % and an accuracy of 67 % in type II. MRA classification and arthroscopic findings were concurrent in 16 (67 %) of 24 shoulders. MR arthrography is a highly effective method for the detection of SLAP lesions, but this technique is limited in the classification of different types of SLAP lesions.

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The slipping phenomenon which is the rentogenographic features and means the non-centripetal relationship in the gleno-humeral joint, especially seen in loose shoulder (LS) patients. Though the abnormal kinematics of the scapula is admitted, there are few quantitative evaluations. The evaluated subjects of the scapular motion consisted of 80 each LS and normal volunteers, using the roentgenograms and for that of the gleno-humeral joint consisted of 7 LS patients and 6 normal volunteers, using the open MRI. Analysis of the scapular motion: the lateral rotated angle was measured of the elevated position. Analysis of the gleno-humeral joint: MR images were extracted at 30 and 135 degrees elevated positions. The description of the bony frame by digitizing using the software was developed from the obtained- images.3D reconstruction images were performed. The reconstructed humeral head was assumed to be a sphere and the position of the center was calculated in the 3D coordinates. The plane formed by the edges of the glenoid was assumed to be the glenoidal plane and the origin of the plane was set. The center of the head was projected to the glenoidal plane and the relationship between its position and the origin was evaluated. The results showed that the translation of the humeral head was small at 30 degrees elevated position in both groups. In the 135 degrees elevated position, the position of the humeral head was located posteriorly and inferiorly in the LS group rather than that of the normal shoulder. The lateral rotation of the scapula tended to be small in the LS group. In conclusion, it is important for the consideration of instability of the shoulder joint to evaluate the kinematics of both the gleno-humeral joint and the scapula, though conventionally it was mainly focused to the movement of the gleno-humeral joint.

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The treatment of chronic unreduced dislocation of the shoulder is a difficult case in shoulder surgery. The purpose of this study was to investigate the clinical results of surgical treatments for chronic unreduced dislocation of the shoulder.25 shoulders of 25 patients were studied. The average age at the time of the surgery was 50 (range: 21 to 73) years old. The period from trauma to surgery ranged from 3 to 72 weeks. We investigated the surgical approach, operative findings, complication and postoperative results by JOA score. Three cases were treated by hemi-arthroplasty.22 cases were openly reduced with preservation of the humeral head. The surgical approach combined the anterior and posterior in 9 out of 10 cases of chronic unreduced posterior dislocation. For chronic unreduced anterior dislocation, surgical approach was only anterior. In all cases, pain had decreased and the shoulder joint was reduced. The averaged JOA score improved from 21 points preoperatively to 75 points postoperatively. In 8 cases in which follow-up periods were more than 5 years, there were osteoarthritis changes in the X-ray, however a re-operation was not necessary. When we treat chronic unreduced dislocation of the shoulder surgically, we have to pay much attention to both soft tissues and bones. The combined approach from anterior and posterior is useful for chronic unreduced posterior dislocation. Posterior capsule release is very important for a chronic unreduced anterior dislocation.

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There are a few reports about outcomes of positional posterior instability of the shoulder after conservative treatment. The aim of this study was to investigate the clinical outcome of positional posterior instability of the shoulder treated non-operatively by questionnaire. From 1986 to 2003,19 shoulders of 18 patients who were diagnosed as positional posterior instability of the shoulder. The positional posterior instability of the shoulder was diagnosed by Jerk test. There were 7 females and 11 males. Sulcus sign was positive in 9 shoulders, and anterior apprehension test was positive in 3 and posterior apprehension test is positive in 11. Physical therapy including rotator cuff muscle exercise was given to all cases.
Subjective shoulder instability, pain, and restriction of daily living and sports activities were investigated. The average follow-up period was 8.1 years.
In 14 shoulders, instability was not improved, but pain and restriction of ADL were improved.
In 12 of 16 shoulders who had shoulder pain, pain improved after 1.9 years from the First visit to our hospital. They continued physical therapy for an averaged 2.1 years, while 4 shoulders whose symptoms were not improved and only continued muscle exercise for 0.9 years. Shoulder instability did not improve in 12 shoulders that had multidirectional joint laxity. Restriction of daily activities remained in 4 shoulders. Restriction of sports activities continued in 4 shoulders.
On the basis of these outcomes, patients who have positional posterior instability of the shoulder can be treated conservatively with physical therapy, such as rotator cuff exercise more than 2 years before considering surgical treatments.

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The clinical characteristics of traumatic antnerior shoulder joint instability were investigated in this study. In 1998,67 cases of traumatic anterior shoulder instability were surgically treated (67 shoulders in 67 patients). The subjects consisted of 50 males and 17 females with an average age of 24.1 years old. They were stratified into 2 groups according to the force applied at the initial dislocation (expressed by the severity of the injury): group 1, minor trauma to 31 shoulders; and group 2, major trauma affecting 36 shoulders. The investigation focused on: the scoring system for joint hypermobility (Beighton), the number of dislocations or subluxations and the diagnosis: a recurrent dislocation or subluxsation. In addition, Hill-Sachs and Bankart lesions were evaluated from the analysis of CT images. The Beighton scores and number of dislocations or subluxations did not show significant differences between groups. The Bankart lesion represented an injury more serious than the major trauma group. There were no correlations between the groups given for the applied force and the development of Hill-Sachs lesions. In those cases to which a strong external force was applied when the initial injury occurred, many dislocations were found at the time of an operation.

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The purpose of this study was to investigate the early phase of the muscle power recovery in the shoulder rotational motion after open Bankart and modified Bristow procedure to make a basis for the post-operative rehabilitation program. The early phase of the isokinetic concentric shoulder rotational muscle strength was evaluated in 18 patients treated with open Bankart and modified Bristow procedure. The muscle strength was measured at 1.5,3,4.5,6, and 12 months after the surgery. They were all male Japan Self Defense Force personnel, and their average age at the surgery was 26 years. We measured the peak torques in both shoulders at 60, and 180 deg/sec angular velocities, and calculated the peak torque ratio. The peak torque decreased 50%at 1.5 months after the surgery, but rapidly increased to the preoperative level by 4.5 months. The peak torque ratio decreased to 50% at 1.5 months after the surgery, and gradually increased to 60% at 3 months,70% at 4.5months, and 80% at 6 months. The muscle power recovered as much as the pre-operative level at 12 months after the surgery. The shoulder rotational muscle power is considered to contribute to the stability after surgery for a patient with an anterior recurrent dislocation of the shoulder. We made a postoperative rehabilitation program, however, the effect of the rotational muscle power was not considered in the program. This study showed that the muscle power was well- recovered at the same time as the rehabilitation program, however, the high level of sports activities should be waited for with the peak torque ratio recovery.

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The purpose of this study was to evaluate quantitatively the shoulder joint volume changes after an arthroscopic Bankart repair in traumatic anterior instability. Double contrast CT scans of 19 subjects with no air leakage were taken preoperatively and postoperatively. Included in the study were 12 male and 7 female subjects,13 right and 6 left shoulders, the average age at follow-up of 25 years old(range,14-51 years old) and the average follow-up of 13 months (12-15). The damaged labrum-ligament complex was mobilized and advanced in the superior and lateral directions and fixed on the glenoid with absorbable suture anchors. The joint volume was calculated using the 3DCT method which we introduced at the 31st annual JSS meeting. With the patient in supine position, lcc of contrast agent and 20 cc of air were injected and a 3DCT image was taken with Lemage Supreme equipment (GE) and the joint volumes were analyzed using an Advantage Workstation 2.0. The total joint volume, anterior superior volume (AS), and anterior inferior volume (AI) were measured and compared to the preoperative volumes. In addition, the amount of total shoulder volume that each section accounted for was also calculated. The joint volumes were: Total: pre-op mean 14.1ml (range,9.5-17.5ml), post-op 12.7ml (8.6-15.7ml) (P<0.05), AS: pre-op 2.8ml (1.4-4.7ml), post-op 2.0ml (0.8-5.0ml) (P<0.05), AI: pre-op 4.8ml (2.37.6ml), post-op 3.6ml (2.1-6.1ml) (P<0.01), all revealing statistically significant reductions. The volume percentages of total joint volume were: AS: pre-op 19.8% (range,11.0-29.6%), post-op 15.6% (3.0-39.1%) (P=0.08), AI: pre-op 34.2% (21.7-55.1%), post-op 28.7% (20.3-37.2%) (P<0.05). Arthroscopic Bankart repair reduced the shoulder joint volume by 10%. This procedure was effective in reducing shoulder joint volume and this effect was seen particularly in the anterior inferior volume.

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We have performed the arthroscopic Bankart repair by reposition of bony fragment for traumatic anterior glenohumeral instability with Bony Bankart lesion. The purpose of this study was to evaluate the clinical results and translation of the bony fragment of this procedure and to compare them with those of the case without a bony fragment. We treated 34 traumatic anterior glenohumeral instability by arthroscopic Bankart repair. The cases with Bony Bankart lesion were 10 cases (9 males and 1 female). The averaged age at operation was 23 years old. The mean follow up period was 19 months. The clinical evaluation was performed using the JSS shoulder instability score. The translation of bony fragment was evaluated by CT and 3DCT images. The average postoperative JSS shoulder instability score was 93 points, ranging from 82 to 100 points. The clinical results were excellent in 9 cases, good in 1 case. There was no significant correlation between postoperative JSS shoulder instability score and existence of bony fragment. The mean superior translation of bony fragment was 9.4mm (from 6 to 16 mm) and mean anterior translation was 3.6 mm (from 2 to 6 mm). The gap between the bony fragment and glenoid surface was 2.8 mm (from 1 to 6 mm). There was no significant correlation between the clinical results and the translation of bony fragment. The arthroscopic Bankart repair by reposition of bony fragment for traumatic anterior glenohumeral instability with a bony Bankart lesion had the same favorable results as the case without a bony fragment.

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The purpose of this study was to clarify the effect of conservative treatment for atraumatic unstable shoulders. We retrospectively studied 16 atraumatic unstable shoulders (3 males,13 females) ranging from 12 to 44 years of age (average,24.4 years old ). Four habitual posterior and one anterior subluxation of shoulders, twelve multidirectional instability of shoulders (7 nonoperative treatment and 5 operative treatment at other hospitals)were included. Five cases of the 6 teens were overhead sports players. The mean follow-up was at 22.5 months (range 6-90 months). Rehabilitative exercises for rotator cuff and scapulo-thorax were performed in all cases, exercises for neck and trunk, hip joint and lower extremities were done in some cases. We evaluated the total score and the score of pain, function and stability with the Shoulder Instability Score of Japan Shoulder Society. The total instability score improved from 53.1 points to 66.9 points. The average pain score before rehabilitation was 5.3 points, the function score was 9.8 points and the stability score was 14.7 points. At the time of the last investigation, the pain score was 8.5 points, the function score was 13.1 points and the stability score was 20.3 points. Five cases of operative treatment at other hospitals had lower total points and had no significant improvement of the instability score after rehabilitation. All of the five cases of overhead sports players returned to their preoperative sports level. Conservative treatment for atraumatic unstable shoulder was satisfactory, but rehabilitative exercises for the cases of multidirectional instability who had undergone the surgical treatment at other hospitals were not effective.

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The purpose of this report was to analyze the characteristics of proximal humeral fracture in children. We retrospectively reviewed 45 cases of childhood proximal humeral fracture treated in our hospital and in Nara Medical University. The types of fracture, age or gender were traced on medical records and X-P. Epiphyseal injuries were classified by Salter-Harris(S-H) classification and determined the severity by Neer classification. We excluded the little league shoulder from an S-H type I injury. The study included 19 girls and 26 boys with an average age of 10.1 years old (ranging from 1 to 16). Twenty patients had epiphyseal injuries. They included one S-H type I injury and 19 type II injuries. A case of type I injury was the accident of a 13 year-old girl. It was not a common case. The degree of displacement was determined by Neer's classification. Nine were grade I,3were grade II.5 were grade III and 3 were grade IV. One patient in the Neer grade II.5 in grade III and 3 in grade IV were treated surgically. The remaining 11 patients were treated conservatively. Twenty-five patients had proximal humeral metaphyseal fractures. Twenty-four metaphyseal fractures were treated conservatively, but only one patient was operated with All-in-one nail. All cases healed with good alignment. The fractures in girls appeared most commonly at 9 years old, and those in boys appeared most commonly at 11 years old. Metaphyseal fractures appeared most, commonly at 10 years old, and epiphyseal injuries appeared most commonly at 11 years old. This study showed girls have a tendency to be injured at younger age than boys, and metaphyseal fractures have a tendency to occur in younger, while epiphyseal injuries have a tendency to occur in older.

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We evaluated the general classifications of proximal humeral fracture. In 1934 Codman showed that fractures of the proximal humerus happened along the former line of the epiphyseal union. This idea became the foundation of classification after that. In 1970 Neer classified 7 types of it into the 2-part fracture, the 3-part fracture and the 4-part fracture. This is the classification that reflects the blood supply of the humeral head and indicates a treatment of the fracture, and is one of the classifications which are most used at present. But there are many fracture types which aren't contained in this. Additionally, a discrepancy with the classified grade and serious illness degree, the reproducibility problem and so on were pointed out. The classifications of Jakob in 1984 and AO in 1990 contain more types than the Neer's and they consider the degree of the humeral head bloodstream and the injury. In 2002 Tamai classified it into 4 types from the condition of the lesser tuberosity and evaluated the condition of the soft tissue around the humeral head in the its direction.
To make a classification derive from the Codman theory is easy to understand, but all fracture types of the Codman classification have not been reported yet and the frequency and the convalescence of each type are still unclear. Each classification had merits and demerits and it was difficult to put them into what advantages or disadvantages. In any case, to evaluate a classification, all of the actually occurring fracture types must be grasped. To establish the propriety? of a classification method, we think that we must use an identical classification at numerous hospitals and to accumulate perioperative findings and a lot of treatment results are necessary.

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The purpose of this study was to show the new classification of the 2,3-part surgical neck fractures of the proximal humerus, and to investigate the operative indication and complications of fixation with a Polarus Humeral Nail (PHN) in each group. Seventy-two (50 females,22 males) with 2,3-part surgical neck fractures of the proximal humerus were treated by PHN. The mean age was 67.9 years old (range 31 to 92 years old). According to the length of the surgical neck (long neck means the length of the greater tuberosity is 2 cm or more, short neck means the length of the greater tuberosity is less than 2 cm) and deformity of the humeral head (varus, neutral, valgus), all fractures were classified into 6 groups; 2-part varus-long neck (12 cases),2-part neutral or valgus-long neck (38 cases),2-part varus-short neck (10 cases),2-part neutral or valgus-short neck (2cases).3-part varus (5 cases), and 3-part neutral or valgus (5 cases). In varus-long neck group, all cases were healed, but 4 cases showed a varus deformity. In the neutral or valgus-long neck group and 3-part neutral or valgus group, all cases were healed satisfactorily. In the varus-short neck group and 3-part varus group,12cases showed severe varus deformity and the humeral head was cut out in 6 cases. In the neutral valgus-short neck group, all cases were healed, but subacromial impingement by a locking screw was happened in 2 cases. PHN was very useful for the treatment of the 2-part, neutral or valgus long neck, and neutral or valgus 3-part fractures. The 2-part varus long neck and the 2-part neutral or valus short neck fractures should be treated carefully about the entry point and the depth of the nail in the humeral head. The varus short neck and 3-part varus fracture should be treated more carefully.

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The Neer four-segment classification is accepted as a standard tool for management of proximal humeral fractures. Some fractures, however, do not come under any type in this classification. We reviewed 67 fractures in 66 patients who underwent open surgery for proximal humeral fractures. There were 14 two-part,27 threepart,18 four-part,7 valgus-impacted, and 1 head-splitting fractures. The surgical anatomy of these fractures was divided into 14 possible patterns described by Codman. Excluding valgus-impacted and head-splitting fractures,17 (29%) of the 59 fractures did not come under any category of the Neer classification. These were: (1) 1 two-part fracture (HH [humeral head] + LT [lesser tuberosity] / GT [greater tuberosity] + shaft); (2) 1 twopart fracture (HH + shaft / GT + LT); (3) 2 three-part fractures (HH / LT + shaft / GT); and (4) 13 three-part fractures (HH / GT + LT / shaft). We concluded that fractures that are not described in the Neer classification are not rare, and that the accurate anatomy should be recognized to assess the circulatory status of the humeral head and to choose appropriate treatment.

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In irreparable rotator cuff repair we usually perform patch graft by using autologous femoral fascia or a polytetrafluoroethylene sheet. However, these methods have problems regarding sacrifice of normal self-tissue and foreign body reaction.
Therefore, development of a method regarding rotator cuff regeneration by tissue engineering technique was expected. We reported on an experimental study about rotator cuff regeneration by using a polyglycolic acid (PGA)sheet as a scaffold with bone marrow-derived mesenchymal stem cells. We made a defect of the infraspinatus tendon insertion in 36 shoulders of Japanese white rabbits and filled the defect with poly-lactide caprolactone (PLC) (PLC group), PGA sheet (PGA group), and PGA sheet with cultured mesenchymal stem cells (MSC group). We sacrificed them at 4,8 and 16 weeks after operation, and evaluated them histologically with H-E, Safranin O, and Azan stain and type I and III collagen immunohistochemical stain. In the PLC group, we found massive foreign body reaction around the PLC fibers although they were absorbed gradually, and the cell invasion into the fibers was a little. The arrangement of cells and fibers were irregular and the cartilage formation in insertion was not found. In the PGA group, PGA fibers were almost absorbed at 16 weeks and regenerated fibrous tissues showed the crimp pattern. In insertion we found the 4 layer cartilage pillar pattern but mainly consisted of type III collagen. In the MSC group, we found the 4 layer cartilage pillar pattern regularly in insertion at 8 weeks and more type I collagen was found than type III at 16 weeks. Therefore, rotator cuff regeneration using a PGA sheet with bone marrow derived mesenchymal stem cells had a good capacity of regenerating tendon-bone insertion and producing type I collagen. We thought this method quite useful for regeneration of a rotator cuff defect clinically.

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The purpose of this study was to evaluate the changes in several parts of the shoulder region in the series of individuals suffering from rotator cuff tears and to elucidate the pathogenesis. The BMD was measured by DEXA. In 26 cases of rotator cuff tear, all patients were right-dominant,12 men and 14 women, divided into 4groups,7 men were affected in the right shoulder (group 1),5 men were affected in the left shoulder (group 2),10 women were affected in the right shoulder (group 3) and 4 women were affected in the left shoulder (group 4), BMD of the head of the humerus, greater tubercle of the humerus, minor tubercle of the humerus, surgical neck of the humerus and humeral shaft were evaluated. The average age was 61.5 ± 11.6 years old in men and 63.5 ± 7.4 years old in women. In all groups there were no significant differences (P<0.05) of BMD between the affected side and the unaffected side. However, BMD of all regions in the affected side were lower than those in the unaffected side in men. On the other hand, BMD of all regions in the left side were lower than those in the right side regardless of the affected or the unaffected in women. Then we calculated the mean side-to-side BMD difference (the affected side BMD minus the unaffected side BMD / the unaffected side BMD x 100 (%)). There is significant difference between the group 1 and the group 3, but there is no significant difference between the group 2 and the group 4 in the mean side-to-side BMD difference. In this study there were various patterns in BMD of the shoulder region in rotator cuff tear patients.

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In a previous study, we reported that the prevalence of delamination as high as 82% of our series of fullthickness rotator cuff tears through arthroscopic investigation. However, the pathology of delamination is still unclear. The purpose of this study was to examine the histology of the delamination. Specimens obtained from proximal torn end of delarninated full-thickness rotator cuff tears in 7 patients, including 3 males and 4 females with an average age of 67 years old(range,54-77), during arthroscopic surgeries were investigated. Small pieces of tissue were obtained from both superficial and deep layers and sectioned longitudinally in the direction parallel to the tendon fibers. The specimens were stained with hematoxylin & eosin, toluidine blue, and Masson trichrome. Thickness and degree of degeneration were examined and graded into four types, then the sum of these scores was used for analysis. Thickness and degeneration scores were compared between the two layers. Statistical analysis was performed with paired t-test and Wilcoxon signed-ranks test. The level of significance was set at 0.05. The average thickness of superficial and deep layers was 2.0 mm and 3.0 mm, respectively, and the difference was significant. The average degeneration score was 6.1 points in the superficial layers and 8.1points in the deep layers, and the difference was significant. The present study demonstrated that the deep layers were thicker and more degenerated compared to the superficial layers. These findings suggested that a rotator cuff tear can initiate from the articular side and then extend to the bursal side. We believe that the early degeneration and tear of deep layer is an important factor of the pathogenesis of delamination.

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Functional changes of the long head of the biceps brachii (LHB) tendon with rotator cuff tears are not well known though they present various pathological changes. The purpose of this study was to analyse the relation between the rotator cuff tears and the biceps labrum complex injury like superior labrum anterior posterior lesion (SLAP lesion), LHB tear (L-T) and LHB rupture (L-R). We retrospectively evaluated arthroscopic findings of 127 shoulders of 127 patients, (78 men and 50 women) with surgically treated full thickness rotator cuff tears. The average age at the surgery was 62.5 years old (from 31 to 79 years old). Cofield's classification for rotator cuff tear sizes: small, medium, large and massive was used. Classifications for SLAP lesions were followed by Gartsman et al.; type I SLAP lesions were classified as minor lesions (MI) and type II, III, IV SLAP lesions were classified as major lesions (MA). Patients were divided into three groups as to their age; the thirties and forties were classified as group A (14 cases), the fifties and sixties were classified as group B (81cases) and the seventies were classified as group C (32 cases). We evaluated the relation between arthroscopic findings and each group. Rotator cuff tear sizes were classified as 32 massive,13 large,72 medium and 10 small. We observed 7 L-R and 28 L-T. LHB injuries including both of L-R and L-T were observed more frequently in the larger size of tears. We recognized 69 cases of SLAP lesions: 42 MI and 27 MA. There was no significant difference between age group and SLAP lesion though LHB injuries were observed in the aged group. There was no relation between SLAP lesions and rotator cuff tear sizes. LHB injuries were recognized more frequently in the larger size of tears.

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The purpose of this study was to compare the clinical outcomes of arthroscopic rotator cuff repair with the clinical outcomes of mini-open rotator cuff repair. In this study,50 cases of small to large rotator cuff tears were treated by either arthroscopic (25 cases) or mini-open rotator cuff repair (25cases). The mean age of all cases were 60.5 years old ranging from 42 to 84 years old. At a mean follow-up of 12 months (range,7 to 31months), the clinical results of both groups were compared by means of the JOA scores. Shoulder scores had improved in both groups postoperatively. In the group of arthroscopic rotator cuff repair, JOA scores had improved from 65.7 points preoperatively to 90.6 points postoperatively. In the group of mini-open rotator cuff repair, the scores had improved from 67.3 points preoperatively to 90.8 points postoperatively. No statistical differences in total shoulder score, pain, strength and function were observed in either group. During the follow-up, recurrent tears were seen in one patient in the arthroscopic rotator cuff repair group and one in the mini-open rotator cuff repair group requiring revision open cuff repair. In conclusion, the present study showed that arthroscopic repair of a small to large rotator cuff tear had equal clinical results to a mini-open rotator cuff repair.

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The purpose of this study was to investigate the changes of MRI findings and JOA score of the patients with rotator cuff tear after open tenorraphy. Operated on 28 cases with rotator cuff tear were performed operation and underwent MRI of the shoulder at from 6 to 12 months (short-term group)and at over 13 months (long-term group) after the operation at the Shizuoka Red Cross Hospital from February 2002 to June 2003. Anterior acromioplasty and open tenorraphy were performed mainly using McLaughlin's method by modified Mason-Allen suture. MRI (T2 with fat suppression) findings were classified according to Sugaya's classification(Type I-V). The thickness of the rotator cuff and fat layer were evaluated according to Murals method. Clinical outcome was evaluated by JOA score. In Sugaya's classification,7 cases improved with the grade from Type II to Typel but 1 case worsened from Type II to Type III. Overall the re-tear rate(Types N, V ) was 27.3% and could be confirmed by short-term MRI. In the complete-thickness tear group, the re-tear rate was 12.5% in SSP tendon tear alone and 66.7% in the massive tear group(p<0.05). The re-tear rate of complete-thickness tear with concomitant tear of LHB or SSc tendon was 83.3%, but the re-tear rate of the rest was 6.3%. In the healed group(Type I, II, III ), the JOA score improved significantly from 67.0 preoperatively to 95.4 postoperatively, and in the re-tear group, from 60.1 to 89.8(p<0.05). The preoperative risk factors of re-tear were a massive tear and concomitance of the LHB or SSc lesions. The re-tear rate of a complete-thickness tear was 27.3%, and a re-tear occurred shortly after the operation.

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It may not be possible to completely cover the humeral head with the rotator cuff tendon in old massive rotator cuff tears, because of the reduced flexibility of the cuff caused by muscle atrophy, fatty degeneration and a scarred cuff tendon. We reported on the surgical results, and the evaluation of post- operative cuff conditions by MRIs of a series of cases in which massive rotator cuff tears could not be completely reduced at the surgery. Twelve patients (11 men and 1 woman) underwent open surgery for massive rotator cuff tears. The patients'mean age was 58.7 years old. All the cases were seen as chronic large deltoid cuff tears and the cuff stumps were severely retracted. We used Nobuhara's technique in the antero-lateral approach. We confirmed the type of tear after release of the adhesion on the rotator cuff (sometimes added under the cuff). In 8 cases (A group)both anterior and posterior portion were reduced by this method and anchored into the bone groove, which was dug 10-15 mm proximally from the original position. In 4 cases (B group), only the anterior part was repaired because we were unable to out the posterior. The surgical results were evaluated according to JOA score. The conditions of the anterior and posterior portions of the repaired cuff tendon was examined by MRI (Ti, T2, oblique sagittal, oblique coronal) at the follow up. We divided the cuff tendon into four conditions according to their thickness and evaluated the relation between the clinical results and cuff condition. The mean follow up period was 49.2 months. JOA score improved from 51.2-92.2 points. The A group's scores were superior to B group's scores in abduction power and staying power. The anterior portion of the repaired cuff tendon was confirmed by post operative MRI in the A group, and in 3 patients in the B group. The posterior portion could be confirmed in 4 cases in the A group, but in none in the B group. We were able to get good results in incomplete repair cases. Even if the scarred cuff was anchored at the proximal area from the original position, and if only anterior portion was repaired, this procedure was meaningful to improve the shoulder function.

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It is very hard to reconstruct the shoulder function of a massive rotator cuff tear. The purpose of this study was to clarify the operative indication and the postoperative results of these patients. Twenty-seven cases of massive rotator cuff tear were studied with the shoulder score of the Japanese Orthopaedic Association (JOA). The score of pain, function, active daily living, range of motion, XP, and instability were improved, postoperatively. Total points of the JOA score were 58.1 points, preoperatively. It became to 87.6 points, postoperatively, which was a significant improvement. Totally, results were acceptable, but there were some small recovery cases. We should suture semitendinous and gracilis tendon loops to the intramuscular tendon of the supraspinatus and infraspinatus muscles at first. It was useful to graft semitendinous tendon and gracilis tendon for a massive tear of the rotator cuff, which we could not repair with McLaughlin's method.

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The purpose of this study was to analyze factors that influence the outcome of nonsurgical treatment for partial-thickness rotator cuff tears (PTRCTs). Sixty-one patients with PTRCT included 34 women and 27 men with a mean age of 55.7 years old were evaluated.43 patients had a history of trauma such as a fall or traffic accident. The types of PTRCT were revealed by MRI. A bursal-sided tear of the cuff was observed in 32patients, a joint-sided tear in 20 and an intratendinous tear in 9. All the patients were treated nonsurgically for a mean duration of 5.7 months. Satisfactory results were achieved in 28 patients.33 patients with unsatisfactory results eventually required surgery. Factors of the 33 nonresponsive patients to the 28 responsive patients to treatment were compared. The factors were as follows; characteristics of the patients, range and strength of the shoulder motion, and radiographic factors, such as size of the subacromial spur and acromial morphology. All data were statistically evaluated using a logistic analysis. The significance level was set at P < 0.05, and odds ratios were figured. Identified factors that had a significant difference between the two groups were age, size of the subacromial spur, bursal side tear, and range of forward elevation (FE) and external rotation (ER). Positive correlation was demonstrated in age and range of the motions, and negative correlation in size of the spur. Each ratio of age, size of the spur, bursal. side tear, FE and ER was 3.33, 2.55, 33.33, 1.1 and 1.11respectively. This study suggested that the younger the age, a bursal-sided tear, a large subacromial spur and motion restriction of the shoulder are factors that induce a poor outcome of nonsurgical treatment for PTRCTs.

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According to literature, the re-tear rate following rotator cuff repair ranges from 20 to 90% and the repair integrity is influenced by the preoperative tear size and fixation method. Recent biomechanical studies demonstrated that the double-row tendon to bone fixation excelled in the initial fixation strength and footprint coverage compared to other methods. This study was prospectively designed to report the repair integrity and clinical outcome following arthroscopic double-row repair. A consecutive series of 106 patients with fullthickness rotator cuff tears enrolled in this study. Twenty patients were lost to follow-up or unable to undergo postoperative MRI. Consequently, subjects consisted of 86 patients with an average age of 60.5 year (range,4177). The follow-up rate was 81%. There were 56 small to medium,30 large and massive tears. Clinical outcomes were evaluated at an average of 31 months (range,24-49). Repair integrity was estimated though T2-weighted images of MRI, which was performed 14 months (range,12- 24) postoperatively on average, and was classified into 5 categories: type I, sufficient thickness with homogenously low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, presence of a minor discontinuity; type V, presence of a major discontinuity. The average JOA, UCLA, and ASES score improved significantly to 95.0,32.9, and 94.3, respectively. Postoperative MRI revealed 37 type I,21 type II,13 type III,8type IV, and 7 type V. The overall re-tear rate was 17.4%. The re-tear rate in small to medium tears was 5.3%while 40.0% in large and massive tears. The type V shoulders demonstrated significantly inferior functional outcomes in terms of overall scores and strength to other types of shoulders (p<0.01). Arthroscopic double-row repair demonstrated an improved structural outcome. However, shoulders with a large defect demonstrated a significantly inferior functional outcome.

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The purpose of this study was to evaluate postoperative recurrent impingement after arthroscopic subacromial decompression (ASD) with a minimum follow up of 12 months. Two hundred and thirty-three shoulders (male 147 shoulders, female 86 shoulders) arthroscopically treated with subacromial decompression were retrospectively evaluated. The average follow up was 20.2 months, with a minimum of 12 months. Hawkins impingement test was performed to evaluate the impingement click and impingement pain at 3months and final follow up. We analyzed the correlation between a positive impingement click or pain and related shoulder pathology to elucidate the causes of an impingement recurrence. Negative impingement clicks were observed at 3 months follow up in all cases. However, positive impingement clicks were recognized at final follow up in 35 cases (15%) including negative impingement pain in 24 cases (10.3%). Eleven cases (4.7%)had both positive impingement clicks and positive impingement pain. Upon investigation of these 11 cases, we recognized re-tear of the rotator cuff tendons previously repaired in 7 cases. In 4 cases, we had performed ASD without rotator cuff repairs for massive size rotator cuff tears. Rotator cuff dysfunction was related to recurrence of postoperative impingement.

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This study was aimed to investigate the relationship between the clinical symptoms around the scapula and kinematic differences of baseball pitches in overhand throwers.115 male baseball pitchers were measured with a motion capture system (ProReflexTM MCU-500+, Qualisys Inc, Sweden) after adequate physical examinations. The subjects were classified into the following two groups according to their tenderness around the scapula; group A: without pain (54 cases, mean age: 17 ± 5.4 years old, height: 1.7 ± 0.1 m, mass: 64 ± 13.3 kg), group B: with pain (61 cases, age: 17 ± 4.7 years old, height: 1.7 ± 0.1 m, mass: 64 ± 12.7 kg). The angular displacements of the shoulder, trunk, hip and knee were calculated during pitching motion. These parameters were compared between the two groups. T test was used for statistical analysis, and the p < 0.05 was considered to be significant. At the instant of front foot contact, abduction of the shoulder in group B was smaller than in group A (p < 0.05). At ball release, the trunk rotation and the horizontal adduction of the shoulder in group B were smaller than those in group A (p < 0.05). The hip of the throwing arm side in group B tended to be in adducted and internally rotated position rather than in group A. It is important to investigate the relationship between the clinical symptoms and the motion data of throwers for improving their performance. The results showed that the manner of pitch might have some relations with shoulder pain. In the clinical scene, it was suggested to mind the posture of baseball pitchers to prevent their shoulder pain.

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The objective of this study was to assess the effect of an ulnar collateral ligament insufficiency on shoulder external rotation measurement at 90° elbow flexion. Seven cadaveric intact upper extremities were tested using a custom shoulder-elbow testing system. The upper extremity was fixed at 90° of elbow flexion and neutral forearm rotation. Elbow valgus laxity was measured with 1.5Nm of valgus torque applied at the forearm. Shoulder external rotation was measured by applying 2.8Nm of external torque at the forearm. The humerus was fixed for measuring elbow valgus laxity and freed for the shoulder external rotation measurement. Data were recorded at each of the following conditions: 1. Intact,2. After splitting the pronator muscles at the elbow and venting the elbow joint capsule,3. After cutting the posterior band of the anterior oblique ligament of the ulnar collateral ligament,4. After cutting the anterior oblique ligament completely. After the posterior band of the anterior oblique ligament was cut, the elbow valgus laxity and shoulder external rotation were increased by 3.1 ± 1.3° and 4.1 ± 1.7°. Complete cutting of the anterior oblique ligament resulted in an increased elbow valgus laxity and an increased shoulder external rotation by 9.1 ± 3.1° and 11.0± 2.8°. An increase in valgus laxity was significantly linear correlated with an increase in shoulder external rotation (p<0.01, r=0.96). Shoulder external rotation measurement at 90° of elbow flexion includes a factor of elbow valgus laxity since they are in the same plane and same direction. This study demonstrated that an ulnar collateral ligament insufficiency results in an increased elbow valgus laxity and subsequently leads to an increased shoulder external rotation which was measured at 90° of elbow flexion.

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It is not clear how frozen shoulder is caused even if it is classified as idiopathic, traumatic and diabetics. However frozen shoulder reveals night pain besides shoulder contracture. We focused on the incomplete rotator cuff tear to analyze how night pain occured. We investigated the clinical finding if an arthroscopic cuff repair of incomplete cuff tear was needed to relieve night pain of frozen shoulder. Arthroscopic capsular release was undertaken for the 33 patients of frozen shoulder with an incomplete rotator cuff tear. We separated it into group A (arthroscopic subacromial decompression and arthroscopic capsular release, n=15, average 56.7 years old) and group B (arthroscopic subacromial decompression, margin convergence and arthroscopic capsular release, n=18, average 59.2 years old). The mean period after surgery was 14 months. We released the anterior capsule with VAPR and the lasp was always used for Bankart repair. We analyzed the JOA scores and night pain before and after arthroscopic capsular release in two groups. The JOA score had increased from 44.3 to 80.3 in group A. The JOA score had increased from 45.6 to 92.5 in group B. Night pain had improved in 62% patients of group A, and in 84% in group B. Only ASD and capsular release were not sufficient to improve night pain. Repair of an incomplete rotator cuff tear was useful to improve night pain for frozen shoulder by arthroscopic capsular release.

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In order to evaluate the limitations of conservative treatment for frozen shoulders, we examined several factors in patients who were treated for frozen shoulders conservatively.68 shoulders of 68 patients who were diagnosed with a frozen shoulder by arthrography at their first visit were treated with conservative therapy for 6 months. In the maximum flexed anterior-posterior (A-P) view of the arthrograms, we defined the “joint contructure” as the position of greater tuberosity at the prerotational glide or rotational glide and “normal” as the position of the greater tuberosity at the postrotational glide. Improvements were evaluated based on arthrograms obtained after 6 months of conservative therapy. Next, the range of motions(ROM), age at the first visit, gender, the duration of symptoms prior to the first visit and traumatic presence were some of the factors examined. The conditions of all the patients in whom the greater tuberosity was located at the rotational glide improved in 6 months. They had a wider ROM than those in whom the greater tuberosity was located at prerotational glide. Of the patients in whom the greater tuberosity was at the prerotational glide,32 patients improved within 6 months, but 16 patients did not. In the latter group, the duration of the symptoms prior to their first visit was significantly shorter and they significantly more often had history of trauma. We concluded that in patients with frozen shoulders in whom the greater tuberosity is located at the prerotational glide, the shorter duration of symptoms prior to the first visit and/or the traumatic onset of symptoms contributed to the limitations of conservative therapy for this condition.

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Arthroscopic repair for incomplete rotator cuff tears has some advantages compared with the conventional open surgery. To clear the merits of arthroscopic surgery, we investigated the clinical outcome of the arthroscopic repair on incomplete rotator cuff tears. Thirteen shoulders with incomplete rotator cuff tears were treated by arthroscopy from 2000 to 2005 and followed up for 4 to 35 months (average 12.6 months). There were 9 males and 4 females with an average age of 62.7 years old. The pre and post-operative results according to the shoulder evaluation sheet of the 'Japanese Orthopaedic Association (JOA score) were evaluated. There were 5 bursal side tears,1 intratendinous tear, and 7 articular side tears. Reattachment of the rotator cuff to the greater tuberosity was performed using anchor system arthroscopically. In cases of intratendinous tear or articular side tears, trial incisions were performed from the bursal side arthroscopically (bursoscopy). After the part of the tear was determined, a rotator cuff repair was performed in the same manner. The average preoperative JOA score was 65.4 points and the average postoperative JOA score was 95.2 points. The average postoperative JOA score improved compared with the preoperative JOA score statistically. The average preoperative JOA pain score was 92 points and the average postoperative JOA pain score was 28.8 points. The average preoperative JOA function score was 13.9 points and the average postoperative JOA function score was 19.3 points. The average preoperative JOA ROM score was 22.5 points and the average postoperative JOA ROM score was 27.2 points. Each average postoperative JOA score improved compared with the preoperative JOA score. The clinical outcome of our arthroscopic repair surgery for incomplete rotator cuff tears was excellent.

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The purpose of this study was to investigate the clinical outcome of arthroscopic rotator cuff repair (ARCR). From July 2001, thirty-nine cases of rotator cuff tears were treated arthroscopically by the author (M. O. ). The patients consisted of 29 males and 10 females with a mean age of 62 years old. The mean pre-operation period was 2 months, and the mean follow-up period was 22 months (12-46 m). After examination under anesthesia, the operation was performed in the lateral decubitus position.
Concomitant lesions were treated, followed by subacromial decompression, rotator cuff repairs with suture anchors by a double-row anchor fixation technique. The clinical outcomes were evaluated using the JOA score. The tear was incomplete tear in seven shoulders, small in five, medium in twenty-one, and large in six. Additional procedures for concomitant lesions were included manipulation for three shoulders, capsulotomy for two, labral repair for two, ganglion resection for one, Mumford procedure for one, and biceps tenodesis for one (including overlap). The mean JOA score had increased from 65 points to 95 at the final follow-up time. One patient with an incomplete tear underwent a re-operation. On the whole, the clinical outcome of the ARCR was satisfactory.

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A morphological measurement is important in development of a shoulder prosthesis, but there is almost no fundamental research on the shape of a proximal humerus medullary cavity using a 3D-CT. The shape of the proximal humerus bone medullary cavity was measured by 3D-CT. The medullary cavity occupation rate(MCOR)of the prosthesis(Physio Shoulder System, JMM)developed for the Japanese. The subjects were 50Japanese humerus(33males, l7females, average age 55.2 years old). The longitudinal length of the humerus, the cross-section areas and the volumes of medullary cavity were analyzed using an analysis software (Osiris, University Hospital of Geneva) by CT images. MCORs of the stem were calculated. The length of the humerus was an average of 288.4mm. The area of medullary cavity at the central part was larger than at the proximal part of the humerus. The area gradually decreased from the proximal to distal part. The volume equivalent to the range of 3cm from the proximal end of the stem was an average of 159.0cm2(standard deviation 47.6), and MCOR was an average of 55.0%(SD 0.1). In addition, the volume of medullary cavity equivalent to the range of 3cm from distal end of the stem was an average of 28.8cm2(SD 12.7), and the MCOR was an average of 80.0%(SD 0.1). MCORs of the proximal part were low. The diameter of the stem is uniform may be the cause. The bigger diameter of the proximal stem was better for rheumatoid arthritis and osteoarthritis, because MCOR was high and primary fixation strength was high. However, the uniform diameter of a stem was better for the deformity after a humerus fracture. The shape of a proximal humerus medullary cavity and MCOR were measured by 3D-CT. MCOR of the proximal part of the stem was low.

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The failure of a manipulative reduction of an anterior dislocation of the shoulder is rare. In elderly cases who demonstrate fragility caused by osteoporosis, the risk of a fracture increases during a reduction. We reported on a case of osteochondral fracture of the glenoid treated with an osteochondral graft. A 65-year-old woman dislocated her right shoulder when she fell forcefully. Initial radiographs showed an anterior dislocation without any fracture. A manipulative reduction by Hippocrates' maneuver was attempted, but concentric reduction could not be achieved. A second radiograph revealed a fragment on the posterior glenohumeral joint and a defect in the anterior glenoid rim. In operating findings, a cartilage defect was observed which covered 60% of the joint surface. The fragment was reduced anatomically, fixed with two absorbable pins and two cylindrical osteochondral grafts from the medial patellofemoral joint were transplanted to the glenoid cartilage surface using the press-fit technique to compress the floating edge of the fragment.20 months after surgery, the elevation was 140°, while the external rotation was 45° and the shoulder remains reduced and stable without pain. In this case, we chose an osteochondral plug, which utilizes a press fit technique. As a result, we were able to fix the large joint surface fragment firmly. The osteochondral graft procedure was described as an alternative method to fix the large joint surface fragment of the shoulder.

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A 22 year old male who fell while snowboarding complained of upper left chest pain.
He had been diagnosed with posterior sternoclavicular dislocation (S-C dislox) at another institute. Upon inspection, the usual protrusion around the stemalclavicular joint (SCJ) was not evident, but tenderness was observed. ROM of the left shoulder was limited due to pain. Radial artery was palpable, but the patient complained of irritation when swallowing. MR angiographs showed that the displaced clavicle end was attached to the aorta. Closed reduction according to Buckerfied's method was performed approximately 192hours (8 day) after injury. At first, reduction was not achieved. It was accomplished by clamping the proximal end of the clavicle using bone forceps. Once the reduction was completed, stability of the SCJ was obtained. The shoulder was immobilized with a figure-of-eight clavicular strap immediately after reduction. Pain during swallowing resolved after emergence from general anesthesia.
4 weeks follow-up, both radiograph and 3DCT showed complete reduction of the SCJ without any instability and shoulder disability. A posterior S-C dislox is an extremely rare injury, the dislocated proximal end of the clavicle may cause injuries to the esophagus, trachea, aorta, and the brachial plexus. Many authors have reported that closed reduction is difficult if not performed within 48 hours after the injury.
Nevertheless, we were able to achieve reduction at 192 hours after injury. We suspect that by holding the proximal end of the clavicle using. bone forceps along with Buckerfield's method, reduction might be easily accomplished.

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