The purpose of this study was to reveal the detailed layered structure of the rotator cuff with regard to the coraocuhumeral ligament by dissecting anatomical specimens of adult shoulders. 53 shoulders of 39 adult cadavers were used for this study. After resecting the acromion, the connective tissue was carefully removed and the layered structure of the rotator cuff on the superior portion of the greater tuberosity was observed macroscopically. The connective tissue between the posterior edge of the coracoid process and the rotator interval, which was not a ligamentous tissues, was observed and then recognized as the coracohumeral ligament by its pathway. The coracohumeral ligament splayed out the supraspinatus and infraspoinatus tendon. After removing both tendons, the coracohumeral ligament was observed to fuse with underlying capsule and extended to the greater tuberosity. However in 20 out of 53 specimens, the superficial distribution of the coracohumeral ligament was restricted to the narrow region. In 11 out of 20 specimens, the pectoralis minor tendon unusually ran beyond the coracoid process and disturbed the development of the coracohumeral ligament. In the other 9 specimens, the supraspinatus tendon was unusually inserted to the lesser tuberosity and interrupted the development of the coracohumeral ligament. This result suggested that the layered structure of the rotator cuff with regard to the coracohumeral ligament was affected by the insertion pattern of the supraspinatus tendon and the pectoralis minor tendon.

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To compare the pullout strength of different types of suture anchors for a rotator cuff repair. 4 types of metallic suture anchors (FASTIN RC anchor^TM, Mitek; Corkscrew^TM, Arthrex; Super Revo anchor^TM, Linvatec; TwinFix^TM, Smith & Nephew) (6 per group) were inserted into 3 different densities of urethane-made blocks (10, 15, 20 lb/ ft³). The original sutures in each anchor were replaced by 2 threads of stronger type sutures ( #2, Ultrabrade^TM, Smith & Nephew ). Anchors were inserted perpendicular to the block surface and then pulled reversely. Both failure load and failure mode were recorded. Data were analyzed using a Bonferroni/Dunn multiple comparison procedure. In the urethane blocks of 10 and 15 lb/ ft³, the average failure load was 127N and 265N for FASTIN, 151N and 297N for Corkscrew, 154N and 312N for Super Revo, 153N and 348N for TwinFix respectively, all of which failed between the anchor and the block. In the urethane blocks of 20 lb/ft³, the sutures failed at approximately 500N of failure load in all anchors, and therefore anchor pull-out tests were interrupted. In the 10 lb/ ft³ block, there were no significant differences in failure load among 4 types of anchors. In the 15 lb/ ft³ block, FASTIN had a statistically significant lower failure load than the other anchors (p<.01), and TwinFix had a statistically significant greater failure load than the other (p<.01). There were no significant differences in failure load among any type of anchor in a low-minute urethane block, while in a middle-minute urethane block TwinFix had a significant greater failure load.

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The purpose of this study was to investigate glenohumeral translation in-vivo during active shoulder abduction in the scapular plane. 9 healthy shoulders in 9 subjects were studied. CT scans of each shoulder were acquired and 3D models of the scapula and humerus were created. The subject was positioned in front of a fluoroscope and motions were recorded during active abduction in neutral rotation in the plane of the scapula. 3D motions of the scapula and humerus were determined using model-based 3D-to-2D registration. A custom program was used for the shape-matching procedure to obtain 6 degrees of freedom shoulder kinematics. Glenohumeral translation was determined by finding the location on the humeral head with the smallest separation from the plane of the glenoid. The glenoid center was defined as the mid point of the long axis. Humeral translation was referenced to the glenoid center in the superior/inferior direction. The F-test was used to compare kinematic variability between initial and each positions with a significance set at p=0.05. The humerus moved an average of 1.7mm, from an inferior location to the glenoid center, during arm active abduction. The humeral head was centered within 1mm from the glenoid center above 80° abduction. The variability in glenohumeral translation between shoulders decreased significantly from initial to over 110° arm abduction. Our findings agreed with some authors' observations of inferior-to-central translation of the humerus on the glenoid and behavior as a perfectly congruent ball and socket join with dynamic abduction. We assumed that the humeral translation to the center of the glenoid provides maximum joint congruency for optimal shoulder function and joint longevity. We believe 3D fluoroscopic analysis of shoulder kinematics can provide information important for improved understanding of shoulder function and this information will lead to better strategies to prevent shoulder injuries, enhance rehabilitation, and improve surgical treatments.

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The purpose of this study was to examine the correlation between the humeral head retroversion and the glenoid tilting angle measured using computed tomography (CT). CTs were done on 64 shoulders of 32 healthy volunteers and 50 shoulders (normal side) of the 50 patients with unilateral posttraumatic recurrent anterior dislocation. The humeral head retroversion was determined with the humeral head axis and the cubital axis. We adopted our original measuring method utilizing Nobuhara's anatomical axis to draw the humeral head axis. The cubital axis was drawn as the tangent to the articular surface. We adopted Randelli's method to determine the glenoid version. The glenoid tilting angle was recorded as a positive value if the glenoid was open anteriorly (anteversion). We also examined the differences between the dominant and non-dominant sides. The mean value of the humeral head retroversion was 32.3±9.5°(12.4∼57.2°), and that of the glenoid tilt was -0.7±3.4°(0∼7.0°). There was no evident correlation between them as evaluated with Spearman's rank correlation (rs=0.31, p=0.01). There were 30 cases of right-handed and 2cases of left-handed. The mean value of the retroversion on the dominant side was larger than that of the non-dominant side. There was a significant difference between them as evaluated with unpaired t-test (p<0.01). In the non-dominant side group, there was moderate correlation between the humeral head retroversion and the glenoid tilt (rs=0.55, p=0.001), on the other hand, in the dominant side group, there was no evident correlation between them (rs=0.20, p=0.46). It is possible that some acquired elements affect the development of humeral torsion other than the glenoid tilt.

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There are numerous reports of success with an open Bankart repair, using low recurrence of dislocation. Few studies indicate that subscapularis (SSC) tenotomy may result in postoperative SSC insufficiency. The purpose of this research was to measure the subscapularis muscle strength, muscle area and signal intensity by magnetic resonance imaging after the open Bankart procedure.
A total of 22 patients were observed prospectively for a mean of 33 months (range 17-51 months). There were 11men and 1woman. The mean patient age at the surgery was 22.8 years old (range, 18-36 years old). All patients were right-handed. 8 patients had injured their shoulder of their dominant extremity. Internal rotation (IR) at 45 degrees abduction was at 60 degrees per second. The peak torques of both extremities was measured at the day before the operation, 6 months and 12 months after the operation. We calculated the ratio of the affected side to the unaffected side. The peak torques of ER and IR of the pre-operation were 13.5% and 18.5% respectively lower than those of the unaffected side. The peak torques of ER and IR that were measured at 6 months after the operation were 27.6% and 21.1% respectively lower than those of the unaffected side. The peak torques of ER and IR that were measured at 12 months after the operation were 18.4% and 0.2% respectively lower than those of the unaffected side. The area at 12 months after surgery was not significantly different from the preoperative area. However, the signal intensity at 12 months after surgery was significantly higher than that in the preoperative signal intensity. An open Bankart procedure using an L-shaped tenotomy approach did not decrease SSC muscle strength and volume. This procedure approach may lead to the deterioration of the subscapularis muscle.

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We wish to report on the long-term postoperative results of a Bankart and modified Bristow procedure for the treatment of recurrent anterior shoulder dislocation.There were 27 patients (27 shoulders) who had undergone a Bankart and modified Bristow procedure for the treatment of recurrent anterior shoulder dislocations at our clinics and related facilities and were observed for 10 or more years of follow-up. The patients were 21 males and 6 females with a mean age of 22.9 years old(range: 17-46). Candidates for surgery were cases with a high degree of shoulder instability that caused the shoulder to dislocate easily during daily activities, and cases where a high degree of shoulder stability was required, such as involvement in contact sports. The operation involved a Bankart repair with a capsular shift, with the addition of a modified Bristow procedure. Patients were cleared to resume daily activities without restrictions after 4 weeks, and to participate in sports activities after 3 months. A questionnaire survey was conducted in order to evaluate the patients' ranges of motion, JSS shoulder instability scores, satisfaction, rate of recurrent dislocation, and complications. As X-ray evaluations could not be obtained, the mean JSS shoulder instability score was 86 on a 90-points scale. Regarding patient satisfaction, 24 patients were completely satisfied, 3 were somewhat satisfied, and none were dissatisfied or somewhat dissatisfied. While no recurrence of shoulder dislocation was observed postoperatively, subluxation was detected in 2 patients each only once. The long-term clinical outcome of the reported procedure was favorable, and it was effective for maintaining long-term shoulder stability.

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The purpose of this study was to analyze the relevant factors in recurrent anterior glenohumeral instability with an anteroinferior capsular lesion.
From 1998 to 2005, 294 shoulders with anterior glenohumeral instability underwent arthroscopic stabilization in our institution. A capsular tear was observed in 33 shoulders, which was 15%, and an HAGL lesion was observed in 11 shoulders, which was 4% among the 294 shoulders. The subjects consisted of 44 patients, 22 males and 22 females, with an average age at the time of surgery 32.3 years old. The findings of a preoperative 3-dimentionally reconstructed computed tomography were also assessed. All the patient underwent an-arthroscopic repair.
We classified the capsular lesion through our arthroscopic investigation into 4 types: TypeI: the capsular tear was located only on the glenoid-side, Type II: the capsular tear was spread from the glenoid-side to the humeral side, Type III: HAGL lesion, Type IV: the capsular tear with an HAGL lesion. There were 19 TypeI, 14 TypeII, 8 TypeIII, and 3 TypeIV shoulders. The majority of the type II capsular tears were located between the MGHL and the AIGHL, parallel to the superior border of the AIGHL. We believe that this separation between the MGHL and the AIGHL caused a functional deficit of the anterior capsular mechanism. Furthermore all types of capsular lesions could be an essential lesion causing a recurrent anterior dislocation. However, A TypeI capsular lesion might sometimes be a secondary lesion. The frequently associated bony Bankart lesion or subscapralis tears in older patients seemed to be more responsible for this instability. On the other hand, the TypeII and TypeIII capsular lesion should be an essential lesion causing recurrent anterior dislocation. Because the morphology of the glenoid rim were less affected. We can expect an excellent outcome, through precise anatomical repair of these capsular lesions along with a Bankart lesion.

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The purpose of this study was to clarify the condition of reattachment of the labrum to the glenoid rim after an arthroscopic Bankart procedure using suture anchors with an MR arthrography (MRA). We studied 48 cases ( 35 males and 13 females) after surgery with a recurrent anterior dislocation or subluxation. The patients ranged in age from 16 to 53 years old (average, 24.7). An MRA was performed at an average 11.8 months after the operation. In the MRA with an axial image and an oblique axial image in abduction and external rotation (ABER) position, we evaluated the invasion of contrast materials between the labrum and glenoid rim using the inferior 6 slice images of the glenoid rim. The 576 slices were categorized into 1 of 3 groups : good, fair, and poor. We used the JSS Shoulder Instability Score (Instability Score) for clinical evaluation. Axial images (total of slices : 288) revealed good (83.3%), fair (14.9%), and poor (1.7%). Oblique axial images in the ABER position (total of slices : 288) revealed good (77.43%), fair (19.8%), and poor (2.8%). The clinical results using the Instability Score had no significant differences between the group that had all good results in six slices and the group that had fair or poor results more than 1 slice in 6 slices of axial images and oblique axial image in the ABER position. The healing of IGHL-LC to the medial glenoid neck was recognized in 97-98% of the total slices. A non-union or re-avulsion of the labrum to articular cartilage of the glenoid were recognized in 15 to 20 % of the total slices, however the clinical results of arthroscopic Bankart repair were satisfactory.

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Arthroscopic Bankart repair is one of the useful surgical procedures, but there were problems with the difficult surgical technique and recurrence rate. Lately the knotless anchor was developed, and convenience of arthroscopic surgery was reported on. The aim of this study was to evaluate the clinical results after a Bankart repair with a knotless anchor and to examine the utility for this more than 1 year later.
We evaluated 30 shoulders treated by arthroscopic Bankart repair with a knotless anchor (22 men and women 8 ). The average age at operation was 27.6 years old (15-58 years old). The average follow-up after an arthroscopic Bankart repair was 17.5 months (12 to 35 months). A 1st time dislocation was the cause of injury in all cases, and working hand. The non-working hand did not have this abnormality. The Bankart repair was performed using 3-4 knotless anchors. We evaluated the Rowe scores of the last investigation and the ROM.
We did not recognize a re-dislocation, but 2 shoulders had a subluxsation (6.7%) out of 30 shoulders. The average Rowe score was stability 46.0 points, motion 19.2 points, function 28.8 points, 94.0 points in total. The average of operation side was 103.5°, non-operation side was 108.7°, and the ratio was 95%.
We got good clinical results more than 1 year postoperatively.

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Although arthroscopic techniques for anterior shoulder instability have generally yielded good results and decreased the morbidity, a recurrence has been the most serious postoperative complication. In 2005 we developed a new type of arthroscopic Bankart repair: the double anchor footprint fixation (DAFF) technique. It simulates a conventional open transosseous Bankart repair. The purpose of this study was to introduce this technique and evaluate the short-term surgical results. We investigated 45 shoulders (34 males and 11 females) which underwent a DAFF technique. The mean age at operation was 24.1 years old and the mean postoperative follow-up period was 13 months. DAFF technique was consisted of a trough preparation and double anchor footprint fixation in order to make a larger area of the footprint repair. The shoulders had their internal rotation immobilized for 3 weeks after the operation. We evaluated the postoperative range of motion, return to sports, recurrence and JSS shoulder instability score. Regarding the postoperative range of motion, elevation recovered early, but external rotation could not recover so early. More than 12 months after the operation, 23 patients completely returned to sports, 5 patients returned partially. There was no recurrence of a dislocation. The JSS-SIS improved from 52.9 preoperatively to 94.9 postoperatively. An arthroscopic Bankart repair with a DAFF technique could be performed successfully. We need a long-term follow-up and to study more about the time of starting ROM exercises.

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The purpose of this study was to evaluate the technical failure of and complications during an arthroscopic Bankart repair using suture anchors for recurrent anterior dislocation of the shoulder. This procedure was performed between January 2004 and August 2006 on 34 patients comprising 28 males and 6 females with an average age of 33.5 years old (range, 19-68); the patients were operated on in the beach-chair position under general anesthesia. In 1 case, an anchor was inserted in an incorrect position. In certain other cases, the strands were displaced from the anchors and were loosened. 2 anchors interfered with each other. After the induction of anesthesia, the patients were seated on a surgical table; their blood pressure at that time declined. During the procedure, the head of 1 patient shifted from its original position on the surgical table, depriving the head of support; this led to a practical dislodging of the tracheal tube. After the surgery, we observed both alopecia at the site of external occipital protuberance and axillary nerve palsy. All failures and complications occurred in the 1st 5 cases. The number of occurrences decreased with experience in further cases. After we performed the surgery in 20 cases, there were no failures or complications. Thus, performing the arthroscopic Bankart procedure using suture anchors is difficult for beginners. Based on these findings, generally, technical failure and complications occur in the first 5 cases in particular. Therefore, beginners should perform their first 5 cases of the arthroscopic Bankart procedure using suture anchors under the supervision of an expert surgeon.

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We have performed the arthroscopical Bankart repair for recurrent anterior shoulder dislocation. Rehabilitation after surgery was performed as outpatient or as inpatient. The purpose of this study was to evaluate the clinical results of arthroscopical Bankart repair correlation of the period of hospitalization. We treated 24 recurrent anterior shoulder dislocation by arthroscopical Bankart repair in 2004. The outpatient group was 13 cases and the inpatient group was 11 cases. Sex, the averaged age at operation, the mean follow up period were not significant in the 2 groups. The clinical evaluation was performed using the JSS Shoulder Instability Score. The range of motion and muscle strength were evaluated by Cybex. The average postoperative JSS Shoulder Instability Score was 92.4 points in the outpatient group and 93.4 points in the inpatient group. There was no significant correlation between the postoperative range of motion and muscle strength in flexion, internal rotation and the period in hospital. The range of motion in external rotation at 2 months after surgery and muscle strength in external rotation at 6 months after surgery in the inpatient group was higher than in the outpatient group. The clinical results of recurrent anterior shoulder dislocation correlated the period in hospital as to the range of motion and muscle strength in external rotation at an early stage after surgery.

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We reviewed 397 proximal humeral fractures registered to the JSS database to clarify problems in employing the Neer classification. In addition to 1-, 2-, 3-, and 4-part fractures described by Neer, we accepted valgus impacted fractures (Jakob) as a category of the fracture classification in the current study. It was found that displacement of fractured fragments in 1-part fractures, particularly in those with the fractured surgical neck, were often overestimated by the surgeons as being 2- or 3-part fractures. It was also noted that valgus impacted fractures had been diagnosed as 2-part, 3-part, 4-part, or unclassifiable fractures by the surgeons, suggesting limitations of the original Neer classification for categorizing this type of fracture.

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The purpose of this study was a comparison between the Codman classification (CC) and the Neer classification (NC) based on a data base(cases of multi-center). Simple X rays of 333 shoulders of the data base were investigated. In CC, we defined the type's number clockwise from upward left and judged the fracture in the existence of the fracture line. We examined the relation between NC and C about the flexion angle. Types 2,8,13 and 16 of CC were not included in the data base. There were 4 cases that were impossible to classify by CC, and 27 cases by NC. NC and CC were related as follows: NC Type 1 (CC Types 4,6,7,9,10,11,12,14), 2-II(1.7), 2-III a (1,3,4,5,10,11), 2-III b (4,10,11), 2-III c (1,10,11), 2-IV(1,3,4,9,12), 2-VI a (4,9,12), 3-IV(1,4), 3-V(5), 3-VI a (4), 4(1), 4-VI a (1,12), unclassified (1,3,4,5,6,14,15, unclassified). In the cases of conservative therapy of an NC 2-part fracture, the CC Type 4 had significantly more cases over 120 degrees flexion than Type 11. In the cases of CC Type 4, the cases of less displacement had a significantly better flexion angle. Therefore NC was better if it had more patterns of classification and CC was better if it had a concept of the displacement.

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Codman showed that fractures of the proximal humerus occurred along the former lines of the epiphyseal and there were 14 types of fracture. Neer classified 7 types of fractures into a 2-part, 3-part and 4-part fracture(group 1) and this classification had a correlation with vasculality of the humerus head and selection of treatment procedures. However, there are few reports about the other 7 types of fracture(group 2) and there was no classification of the fractures. We studied 603 fractures of the proximal humerus in 603 cases by evaluating X-ray films. 266 were males and 337 were females. The average age was 52.6 years old(range: 18∼99). We classified these fractures by Codman classification. 19 fractures (3.1%) came under group 2. They were (1)(HH:humerus head)+(GT:greater tuberosity • LT:lesser tuberosity)+(shaft) 6 fractures, (2)(HH )+(GT • shaft)+(LT) 1 fracture, (3)(HH)+(LT • shaft)+(GT) 7 fractures, (4)(HH • shaft)+(GT)+(LT) 3 fractures, (5)(HH • shaft)+(GT • LT) 1 fracture, (7)(HH • LT)+(GT • shaft) 1 fracture.8 of these fractures came under Neer's minimally displaced type, 3 fractures Neer's 2-part fracture and 8 fractures(1.3%) were not described in Neer classification.
Fractures that were not described in Neer classification were rare(1.3%). We could manage these fractures respecting Neer's concept of assessing the circulation of the head and degrees of displacement and current knowledge of the humerus head circulation. So we conclude that Neer's classification was practical.

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Displaced 4-part fractures of the proximal humerus carry a significant risk of avascular necrosis (AVN). Recent reports showed incidence of AVN in some subtype of 4-part fractures was low. The purpose of this study was to show the new classification of the 4-part fractures of the proximal humerus and to report the incidence of AVN in each group. This study consisted of 51 cases (37 females, 14 males) with 4-part fractures of the proximal humerus. The mean age was 66.8 years old (range 29 to 88 years old) 4-part fractures without a dislocation were classified into 4 groups (valgus type, varus type, split head type, other type). 4-part fractures with a dislocation were classified into 4 groups (valgus impacted subcoracoid type, displaced subcoracoid type, axillary type, posterior dislocation type). In the valgus group (18 cases; open reduction and internal fixation (ORIF): 12 cases, prosthetic replacement: 4 cases, conservative treatment: 2 cases), no cases showed AVN. In the varus group (8 cases), all cases were treated by ORIF, 1 case showed AVN. In the split head group (4cases; ORIF: 3 cases, prosthetic replacement: 1 case), all 3 cases healed without AVN. In another group (4 cases; ORIF: 3 cases, prosthetic replacement: 1 case), 2 cases showed AVN. The valgus impacted subcoracoid group consisted of 6 cases (ORIF: 1 case (AVN(-)), prosthetic replacement: 5 cases), the displaced subcoracoid group consisted of 5 cases (ORIF: 3 cases (1 case, AVN(+)), prosthetic replacement: 2 cases), the axillary group consisted of 5 cases (ORIF: 1 case (AVN(+)), prosthetic replacement: 3 cases, resection: 1 case), and posterior dislocation had 1 case (prosthetic replacement). 4-part fractures without a dislocation were almost treated satisfactorily by ORIF without AVN. ORIF for 4-part fractures with a dislocation was challenging, but some cases may have healed without AVN by minimal invasive reduction and internal fixation.

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We investigated the clinical results of displaced proximal humeral fractures treated by plate, anterograde wiring, retrograde wiring and an intramedullary nail fixation. We evaluated the risk factors from the cases of complications occurred.
(Materials and methods) one hundred and ten shoulders of 110 patients (26 males, 84 females, mean age 68 years old) underwent open surgery by pinning (28 cases), intramedullary fixation (62 cases) and plate fixation (20 cases). Fracture types were a 2 part A2 (44 cases), A3 (21 cases), 3 parts B1 (40 cases), and B2 (5 cases). From the clinical results we assessed the risk factors including age, fracture type and fixation method.
Ten of 110 cases were cutout. The mean age was 68 years old(54-85). Six of 28 cases were pinning, 3 of 20 cases used a plate, and 2 cases of 62 the nail was cutout. In the type of fracture, 4 of 44 cases in A2, 5 of 21 cases in A3, 1 of 40 cases in B1, and 1 of 5 cases in B2 were cutout. The cutout risk was significantly increased in the pinning surgery, and the A3 fractures. In the cutout rate of pinning the risk of fractures was significantly high.
Cutout risk was significantly increased in the type of unstable A3 fractures. Unstable A3 fractures were not suitable to pinning.

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The purpose of this study was to investigate the clinical results of the internal fixation using Polarus humeral nails for fractures of the proximal humerus. Ninety-three shoulders of 93 patients (20 males, 73 females) underwent the intramedullary fixation using Polarus humeral nail from October, 2000 to May, 2006. Mean age was 69 years old (50-92) at surgery and average follow-up period was 7.8 months (3-14) after surgery. Fracture types were 2-parts (49 shoulders), 3-prats (36 shoulders) and 4-prats (8 shoulders) by Neer classification. We evaluated the pain score by JOA, the range of motion and postoperative complications in clinical results, and the bony union, the status of reduction at surgery and the varus deformity during postoperative course in radiological findings. All the patients who underwent oateosynthesis obtained a bony union and there was no osteonecrosis of the humeral head. The postoperative pain score was a mean 26 points (20-30) and the range of motion of the shoulder joint was a mean 119 degrees (40-180) in elevation, 36 degrees(-20-85) in external rotation and L2 (B-T6) in internal rotation. Clinical and radiological outcome of the proximal humeral fractures with Polarus humeral nail was satisfactory in 2-part, 3-part and some of the 4-part fractures. Proximal screws in 20 shoulders had to be removed of backed out and/or impingement, but these complications were improved by a secure fixation with the locking screw. The intramedullary humeral nail can be one of the effective method for the treatment of proximal humeral fractures.

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We studied the clinical outcome of shoulder hemiarthroplasty. 9 patients (8 females, 1 male) with proximal humeral fractures including 5 acute fractures, a non-union of a surgical neck fracture, and 3 revisions for the failure of osteosynthesis, were treated by hemiarthroplasty. Their mean age was 69.4 years old (range 53 to 84 years old). The mean follow-up period was 9 months (range, 6 to 23 months). Clinical outcome was evaluated according to the Japanese Orthopaedic Association (JOA) score. The mean JOA score was 61.5 (range 39 to 83 points). The operating time and bleeding were 2 hours 26 minutes and 236g, respectively. 2 of 3 patients with a revision had postoperative complications. 1 had loosening of the stem and another had a subluxation of the humeral head. Hemiarthroplasty of the shoulder is a good surgery for the treatment of proximal humeral comminuted fractures in terms of pain relief. However, there was only moderate functional improvement especially in patients with a previous surgery than those with acute fracture.

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The purpose of this study was to show the usefulness of the reconstructed coronal and sagittal views after an arthrographic helical computed tomography (HCTA) to perform the minute evaluation of the delamination of the rotator cuff tear (RCT). Our subjects consisted of 32 shoulders of 31 cases with RCT, 22 men and 9 women with a mean age of 55.0 years old. They were classified into the following 3 groups according to their tear size; small tear (9 subjects), medium tear (8 subjects), and large tear (15 subjects). We assessed the size and position of the delamination of the RCT with HCTA, and their relation to age and size of the RCT. A delamination was exhibited in the 20 subjects of 32 (62.5%) with a mean age of 58.0 years old. The group with a delamination was older than that without a delamination with a mean age of 50.1 years old. As to the size of the RCT, a delamination was found in 2 of the 9 small tear subjects (22%), all 8 medium tear subjects, and 10 of the 15 large tear subjects (67%). The evaluation of the sagittal image showed that the subjects with a wide delamination from the SSP to the ISP (59.3 years old) were older than the others with only an SSP delamination (52.0 years old). The HCTA was one of the most useful examinations for the preoperative minute evaluation of the size and position of the delamination of the RCT.

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The optimal position of the humerus when evaluating rotator cuff tears on MRI has yet to be determined.Obtaining a reproducible MR view without individual differences is important but it is sometimes difficult because the inclination of the scapulars are different. We defined the ideal position of the humerus during MRI as follows: 1. Supraspinatus muscle runs straight and is parallel to the scapular plane. The center of the insertion of the supraspinatus tendon was nearly at the border between the superior and inferior facets (S/M border). We rotated the humerus so that the scapular plane was parallel to the S/M line. The S/M angle was defined as the angle between two lines drawn from the center of the humeral head to S/M border and to the bicipital groove. We defined θ as the angle between the scapular plane and the horizontal plane, and β as the angle made by the line drawn from the center to the bicipital groove and the axis of the flexed forearm. The internal rotation angle of the humerus was caluculated as θ + S/M angle+β - 90. Each facet on MR view was investigated. The S/M angle of 50 shoulders converged at 45.4°. θ of 140 shoulders varied. β was 15.2°. The internal rotation angle was expressed as θ - 30, mean 15°. Each facet was easy to evaluate. Rotating the humerus so that the scapular plane ran at S/M border 45°to the bicipital groove produces high quality images.

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The purpose of this study was to clarify the merit of our operation method for a massive rotator cuff tear. If suturing by McLaughlin's method after abrasion and traction of torn cuff provided insufficient covering of the humeral head, we chose fascial patch procedure using our standardized technique. In our protocols of patch procedure, the important points were sewed graft to the torn cuff edge firmly by the double mattress suture technique, anchored the tendon to the anatomical foot print of the major tuberosity, and removed an adequate thick graft with a single layer from the fascia. 28 operated patients with a massive rotator cuff tear were evaluated one year after operation. McLaughlin's method was performed on 10 patients and fascial patch procedure was done in 18 patients. Repair integrity was estimated by Sugaya's classification through MRI. The rate of healed case( Type I, II, III ) was 90% in McLaughlin's method, and 92.9% in the patchprocedure. The mean JOA score improved from 62.1 to 90.6 in McLaughlin's method, and from 56.9 to 90.3 in the patch procedure. All the cases returned to their jobs. A rate of successful anatomical healing rate must be respected as an index to judge whether operation methods are proper. Both of the rate and clinical outcome of our methods were satisfactory.

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The present study was an attempt to evaluate the clinical outcomes of patients with a full-thickness rotator cuff tear treated by mini-open or arthroscopic rotator cuff repair (ARCR). 24 shoulders in 23 patients were included in this study. There were 15 male and 9 female patients with an average age of 64.1 years old (range, 41 to 80). The length of the greatest diameter of the tear was divided into 4 categories of tear: small (1 centimeter or less), medium(1 to 3 centimeter), large(3 to 5 centimeter), and massive (greater than 5 centimeter). By these criteria, there were 1 small, 10 medium, and 13 large tendon tears. The acromio-humeral distance was measured for the index of the upward migration of the humeral head. The clinical outcomes were assessed on the basis of the Japanese Orthopaedic Association (JOA) shoulder score. The JOA scores increased from an average of 62.2 points preoperatively to an average of 88.7 points postoperatively by mini-open repair, and an average of 54.4 points preoperatively to an average of 91.0 points postoperatively by ARCR. There was a tendency that the postoperative JOA scores of a large tear were lower than those of a medium tear. There was a statistical correlation between the postoperative JOA scores and the acromio-humeral distances in the ARCR group.

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A rotator cuff tear is classified into a full thickness tear and a partial thickness tear. Various visual analog scales (VAS) of the shoulder joint in cases of rotator cuff tear were evaluated preoperatively. These scales included evaluations at night, at the time of exercise and at the time of rest. The purpose of this study was to examine the characteristics of each VAS evaluation into 3 types of rotator cuff tears. Since January 1999, 123 patients of rotator cuff tears were operated on in our institute, and 86 of them were evaluated preoperatively about their VAS. Their mean age was 61.8 years and the mean affected period was 20.2 months. There were 52 males, and 34 females. Each case was classified into the articular side tear group (group A), the bursal side tear group (group B) and the complete tear group (group C). The VAS evaluations of each group were statistically evaluated (The Tukey-Kramer method). There was not significant difference between the age and affection period of each group and there was significant difference about various VAS evaluations.

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Comparisons were made to identify the transition of pain-relieving doses and their inflammatory reaction after an arthroscopic (Method-A) or a mini-open rotator cuff repair (Method-M). We reviewed the cases of mini-open-group (Method-M) including 8 males and 9 females of ages 51-71 average 62.4 and the arthroscopic-group (Method-A) including 16 males, and 22 females of ages 25-83, average 63.1. Method-M group underwent operations 10 cases/right and 7 cases/left, using 2.2 suture anchors for 178 minutes average with a follow-up of 2.8 years. Their average JOA shoulder score improved from 59.5 (pre/operation) to 94.5 when reviewed. While, method-A underwent operations 28 cases/right and 10 cases/left, using 2.1 suture anchors, for 189 minutes with a follow-up of 1.6 years. Their average JOA shoulder score improved from 59 to 94.4. We investigated the dosing frequency of postoperative pain-relief on the operation date and the postoperative 1/2/3/4/5 days. Diclofenac sodium suppository 25mg was dosed 0.7/0.7/0.3/0.1/0.1/0 times to the Group M, while 0.6/0.3/0.3/0.2/0.1/0 to the Group A. Significant difference was identified only in the first postoperative day (P=0.005) . Pentazocine intramuscular injection 15mg was dosed 0.7/0.4/0.3/0/0/0 times to the Group M, while 0.4/0.1/0.1/0/0/0 to the Group A with no significant differences except on the first (P=0.001) and second (P=0.002) postoperative days. Blood cell count transited similarly for both. The preoperative and postoperative (1st/4th/7th/14th/21st day) average CRP were respectively 0.1/3.1/4.9/1.1/0.3/0.1 mg/dl for the Group M, while 0.1/1.8/2.8/0.8/0.2/0.1 mg/dl for the Group A with no significant differences except on the first (P=0.0005) and 4th (P=0.0007) postoperative days. Method -A indicated less postoperative pain of the objectified scores, and less increase of CRP than method-M.

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Shoulders with rotator cuff tears were divided into 3 groups according to pain: those who have pain at present (symptomatic group), had pain in the past but not at present (ex-symptomatic group) and have not had pain (asymptomatic group). The purpose of this study was to clarify the differences in muscle strength among these 3 groups with isolated tears of the supraspinatus. There were 31 shoulders in the symptomatic group, 21 in the ex-symptomatic group and 66 in the asymptomatic group. The abduction strength and external rotation strength in adduction were assessed with the use of a manual muscle test and compared among the groups. Abduction weakness was observed in 52%, 33% and 38% in the symptomatic group, the ex-symptomatic group and the asymptomatic group, respectively. There were no significant differences among them. Weakness in external rotation was observed in 52%, 10%, and 39% in the symptomatic, ex-symptomatic, and asymptomatic groups, respectively. External rotation strength was significantly weaker in the ex-symptomatic group than the others (symptomatic and ex-symptomatic group, p=0.002; ex-symptomatic and asymptomatic group, p=0.01). Well preserved strength in external rotation is characteristic to ex-symptomatic shoulders with isolated tears of the supraspinatus.

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Treatment of irreparable rotator cuff tears remains controversial. Infraspinatus / teres minor transfer to the greater tuberosity has been proposed for the treatment of irreparable tears associated with severe functional impairment and chronic, disabling pain by Paavolainen et al. in 1990. After that, however, there were few reports of mid- or long-term follow-up studies. Our purpose of this study was to investigate and analyze the results of the Paavolainen's procedure over 3 years. From 1986 to 2003, 18 patients with 18 irreparable, massive tears were managed with an Infraspinatus / teres minor transfer and were evaluated clinically and radiographically after an average of 5.7 years. The study group included 9 men and 9 women, with an average age of 66.9 years old at the time of the surgery. The outcome assessment included the JOA and DASH scores and the range of motion of active flexion and external rotation. Osteoarthritis and upper migration of the humeral head were evaluated on standardized radiographs. The mean JOA score improved from 45.7 preoperatively to 74.6 at the time of the follow-up. The mean postoperative DASH score was 27.9. Flexion increased from 82.5° to 123.4°. There was no significant improvement in external rotation. 15 had significant progress of the osteoarthritic change and 13 had progress of the upper migration of the humeral head. 12 patients were satisfied with their shoulder condition. 3 shoulders had rupture of the transferred tendon and another had humeral head replacement with a latissimus dorsi transfer. Though the disabling pain improved in most patients, the osteoarthritic change progressed in 83.3% and further long-term follow-up was necessary.

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Delamination is 1 of the horizontal tears' morphology observed in full-thickness rotator cuff tears. However, this pathology is not well known about in detail. The aim of this study was to investigate the characteristics of delamination by arthroscopic evaluations.
We retrospectively evaluated arthroscopic findings in 162 patients (100 males and 62 females) with arthroscopically treated full-thickness rotator cuff tears. The average age at the surgery was 62.2 years old (from 31 to 79 years old).
Cofield's classification for rotator cuff tear sizes: small, medium, large and massive was used. Patients were divided into 3 groups as their age; the 30s and 40s were classified as group A (21 cases), the 50s and 60s were classified as group B (102 cases) and the 70s were classified as group C (39 cases). We evaluated the relationship between arthroscopic findings about delamination and each group.
Delamination was observed in 60 cases (38 males and 22 females) (37.0%).
Delamination was not observed in 102 cases (62 males and 40 females) (63.0%).There was no statistical relationship between frequency and gender. Frequencies of delamination in each tear size group were as follows. massive: 14/39 (36%), large: 9/20 (45%), medium: 33/84 (39%) and small: 4/19 (21%).
There were low frequencies in the small size group compared to the larger size groups.
Frequencies of delamination in each age group were as follows:Group A: 10/21 (48%), group B: 37/102 (36%) and group C: 13/39 (33%). There were high frequencies in the youngest age group compared to the older age groups. Frequencies of delamination was lowest in the small size tear group and it was highest in the youngest age group.

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The purpose of this study was to evaluate the changes with time of the muscle strength of the shoulder and the cross-sectional area ( CSA ) of rotator cuff muscle after arthroscopic rotator cuff repair ( ARCR ) and to investigate the relationship between the tear size of rotator cuff and the muscle strength and CSA before ARCR. We investigated 20 cases ( 13 males and 7 females ). The mean age at operation was 63.5 years old ( 54 - 78 ). Pre and post - operative muscle strength and CSA were compared at 6 months and 1 year after the operation. We measured the longest anterior posterior diameter ( a ) and the longest transverse diameter ( b ) among the findings at the operation.
11 cases were S size classified in a ≤ 2cm and b ≤ 2cm, 9 cases were L size classified in a > 2cm and b > 2cm. We performed 3 tests as abduction, 2 tests as external rotation and internal rotation. We evaluated the isometric muscle strength of the shoulder using MICROFET. Some physical therapists did these tests 3 times and the results were averaged.
The results were divided by the value of the pre-operative unaffected side. We measured the CSA of supraspinatus, infraspinatus, teres minor and subscapilaris at a slice 1cm medial to the gleno-humeral joint with an MRI oblique-sagittal view of T2.
We used the values that divided the CSA by the head of the humerus area to eliminate any individual difference.
The muscle strength gradually recovered after operation regardless of tear size.
The strength of external rotation showed statistically significant changes at 6 months after the operation.
The strength of abduction and internal rotation showed a meaningful recovery 1 year after the operation.
On the other hand, the CSA did not show any significant changes after the operation.
The pre-operative muscle strength of abduction and external rotation were significantly correlated with the tear size.

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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. We performed experimental study about the rotator cuff regeneration using mesenchymal stem cells with a tissue engineering technique. The infraspinatus tendons of Japanese white rabbits were reconstructed 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. And we measured the ultimate mechanical strengths and Young moduli of these regenerated tendons at 4 and 16 weeks. In the PLC group, we found massive foreign body reaction around the PLC fibers, and 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 the insertion we found the 4 layer cartilage pillar pattern but it 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. The results of mechanical properties show that the regenerated tendons in MSC group had adequate ultimate tensile strengths but had low Young's moduli, that is, are easy to elongate. Therefore, rotator cuff regeneration 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 determine the correlation of acromial spur formation (ASF), degenerative change on the greater tuberosity (GT), and severity of degenerative alteration of the tendon in rotator cuff tears. 100 patients with rotator cuff tears (32 incomplete and 68 complete tears) found surgically were selected to examine the ASF, degenerative change on the GT on plain X-rays and correlate these findings with the severity of cuff degeneration. ASF was divided into 3 types (type I: no spur, type II: spur formation, type III: acromio-clavicular osteoarthrosis). ASF was not related to severity of cuff degeneration, AHI, LAA, age or duration of symptom. We observed an increased incidence of complete tears and traumatic episode in group of type II and increased incidence of type II in the patients with bursal side tears. ASF was also present in the patients with articular side tears. Degenerative change on the GT was correlated with AHI, severity of cuff degeneration, size of tears and age. However, ASF and traumatic episode were not related to the change on the GT. Histologic findings of ASF revealed the fibrosis with vascular proliferation, sclerotic change of the bone, and thickening of the fibrocartilage layer due to the mechanical stress or reactive bone formation. Degenerative change on the GT was associated with severity of cuff degeneration. ASF seems to be the secondary change after a rotator cuff tear since the incidence of a type II and histologic findings.

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There have been no reports that have analyzed changes of the stress distribution in postoperative glenoid cavity using CTOAM. The aim of this study was to investigate change of long-term stress distribution at the subchondral bone of the glenoid cavity after rotator cuff surgery. 9 shoulders in 8 cases with rotator cuff surgery were investigated pre- and post-operatively using CT osteoabsorptiometry (CTOAM). The average age of the patients was 66.3 years old (range: 45-82). 7 shoulders had anterior acromioplasty with a rotator cuff reconstruction and the remaining 2 shoulders had only anterior acromioplasty. The average duration between pre- and post-CT examination was 70.6 months (range: 39-90). The measured Hounsfield Unit values at the subchondral bone plate were mapped in 256 phases of gray scale using custom-made software. Anterior-superior maximum type was found in 3 glenoids, anterior-superior and posterior type in 4 and central maximum with anterior-superior maximum type in 2 before surgery. After surgery, 6 of 7 shoulders which had received rotator cuff reconstruction revealed an increase of stress distribution at the central area of glenoid. The stress distribution at the subchondral bone of glenoid cavity in patients without rotator cuff reconstruction had not changed. In a rotator cuff tear shoulder, stress was concentrated on the anterior-superior and posterior-superior zone by upward deviation of the head of the humerus. After reconstruction of rotator cuff, long-term mechanical stresses were concentrated into the central region and only anterior acromioplasty did not lead to an antero-superior stress distribution.

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A high re-rupture rate after the arthroscopic repair of rotator cuff with large and massive tear were recently reported on MRI study. The objective of this study was to investigate the effectiveness of the new suture technique biomechanically. 18 bovine infraspinatus tendons were repaired to the humerus with 2 suture techniques as follows: A; a dual-row suture technique with four Fastin anchors and tied by using SMC knot, B; knotless suture of the loop from the medially placed 2 Fastin anchors with use of 4 bioknotless anchors C, a pull-out transosseous suture of 8 threads from proximally placed 2 Fastin anchors. The breaking strength, failure mode during tensile testing and the stress distribution immediately after repair of the rotator cuff with these techniques using 3 finite element models were compared. The breaking strength was averaged to 310N in A, 283N in B and 368N in B, respectively. Although a stress concentration was seen around the medial anchor in A, no stress concentration was found inside of the tendon in B or C. A new suture technique could obtain almost the same strength and better stress distribution pattern compared with the dual-row technique.

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The purpose of this study was to investigate the effects on clinical results of the medial shift of the repair site of the rotator cuff. The subjects were 120 shoulders of 120 patients who underwent surgical therapy for a rotator cuff tear more than 2 years prior. The distance from the greater tubercle to the repair site of the rotator cuff was divided by the diameter of the humeral head on the MRI image, and the corrected value was defined as the “distance of the sutured site”. This value was examined with roentgenographic findings, UCLA scores at 2 years after the operation, and muscle strength. Concerning the distance of the sutured site, significant differences were seen in muscle strength as an item of the UCLA scores, ability to elevate to the zero position on an X-ray image 2 years after the operation, and muscle strength (p<0.05). It was suggested that the “distance of the sutured site” was strongly affected by the preoperative rupture size, rather than preoperative adipose degeneration in the fascia of the supraspinatus muscle and changes of arthropathy. The longer rupture size was suggested to result in the risk of a postoperative decline in muscle strength. Moreover, long “distance of the suture site” had the possibility of resulting in a disability to elevate to the zero position. However, the active elevation angle was almost normal due to compensation by the scapulothoracic joint, and was little affected by the “distance of the sutured site.”

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The purpose of this study was to report the surgical results of the repair of massive rotator cuff tears with a fascia lata graft.14 patients had massive rotator cuff tears with fascial patch graft and had from a minimum followup of 1 year to a maximum of 12 years. The 12 male patients and 2 female had a mean age of 63 years old (range from 56 to 72). All patients were evaluated before and after surgery with the shoulder surgery classification system by the Japanese Orthopaedic Association (JOA score). An adequate decompression was made by an anterior acromioplasty. An extensive bursectomy and debridement were also done. A massive rotator cuff tear was identified and mobilized with a traction and a blunt dissection. Ipsilateral fascia lata tendon was dissected and folded in double fashion. With the JOA score system, the results were rated excellent (more than 90 points), good (more than 80), fair(more than 70) and poor (less than 70 points). Excellent results were achieved in 12 patients, good and fair were in 1 patient, and poor in none. The overall JOA score was an average of 93.9 points. We concluded that the repair of massive rotator cuff tears with a fascial graft was a useful method.

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Although rotator cuff tears are being repaired arthroscopically with increasing frequency by orthopaedic surgeons, the arthroscopic repair of subscapularis tears remains a challenge and only few studies have examined treatment outcomes. The purpose of this study was to evaluate the outcome in patients who underwent the procedure. Our prospective study population consisted of 15 patients, 11 males and 4 females, whose mean age was 62 years old (range 52 - 69 years old). The mean duration of follow-up was 33 months (range 25 - 60 months). All had a full-thickness tear of the subscapularis tendon; 10 had a concomitant supraspinatus tear, and 5 had concomitant supraspinatus and infraspinatus tears. The shoulders were evaluated using the JOA score. An arthroscopic suture anchor technique was used for the repair. After arthroscopic repair, the mean JOA scores significantly improved from 54.4 points to 90.1 points (p<0.0001). Rated on the JOA scale, the outcomes were excellent in 8 patients, good in 5, fair in 1, and poor in 1. Preoperatively, 12 patients had a positive- and 1 a negative lift-off test; 2 patients could not be tested as they had a restricted range of internal rotation. The belly-press test was positive in 14 and negative in 1 patient. Postoperatively, 3 patients had a positive and 12 a negative lift-off test; 4 had a positive and 11 a negative belly-press test. Arthroscopic repair of subscapularis tears using the suture anchor technique is a safe and effective procedure with respect to the alleviation of shoulder pain and the improvement of function and range of motion.

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This study investigated the relationship between rotator cuff muscle atrophy and impingement syndrome in gymnasts.22 male elite gymnasts (44 shoulders) were checked up for shoulder problems specially impingement signs. MRI studies were performed for all subjects to measure the cross-sectional area of 3 rotator cuff muscle groups (supraspinatus, infraspinatus + teres minor, subscapularis). The relationship between the impingement sign and cross sectional area of the rotator cuff muscle was investigated. 21 shoulders had a positive for impingement sign. None of the patients showed any rotator muscle weakness on manual testing. MRI confirmed that there was no rotator cuff tear in any patient. On the logistic regression analysis odd ratios were the supraspinatus 2.330, infraspinatus + teres minor 0.796,subscapularis 1.231.Though it was unclear whether atrophy of the supraspinatus muscle was a cause or a result, this study suggested that there was supraspinatus muscle weakness involved in the impingement syndrome in gymnasts. Muscle strength of the supraspinatus was important for both treatment and prevention of impingement syndrome in gymnasts.Atrophy of the supraspinatus was significantly more common in patients with an impingement syndrome.

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A rotator cuff tear with the long head of the biceps (LHB) changing in form or LHB rupture are experienced frequently. This study investigated the characteristics of the rotator cuff tears with the LHB changing in form and a LHB rupture. 200 consecutive shoulders in 197 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 (31 men and 17 women, the changing in form group) and 14 shoulders in 14 patients (11 men and 3 women, the rupture group). The age of the patients ranged from 33 to 84 (mean 61.4) years old of the changing in form group and from 45 to 75 (mean 61.3) years old of the rupture group. Medical histories and operative findings were compared between the changing in form and the rupture group. Additionally, the preoperative and the postoperative results were evaluated using the JOA score. There was no significant difference between the changing in form and rupture groups in age or gender, duration between time of injury and surgery and the JOA scores of the pre-operation and post-operation. Traumatic presence in the rupture group was significantly more than that in the changing in form group (P<0.05). There was no significant difference between the changing in form and rupture groups in the size of the rotator cuff tear. Cases with a subscapularis tear in the changing in form group were significantly more than those in the rupture group (P<0.05). Many of the rotator cuff tears in the changing in form group had a few to traumatic presences and a large with subscapularis tear. We suggested that these appearances of the disease machine beginnings of the 2 groups were not the same.

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Difficulty of shoulder elevation is mainly caused by shoulder disorder. However patients with deltoid paresis by cervical spondylotic amyotrophy (CSA) are sometimes referred to a shoulder surgeon. We reported on the clinical courses of 19 patients with CSA to analyze their clinical features in order to clarify the point of differentiation from shoulder joint disorder. Of 8118 patients who consulted the shoulder service of our department, 162 patients (2%) were diagnosed as having cervical lesion. Nineteen patients were diagnosed as having CSA based on the clinical features, especially, deltoid palsy associated with weakness of the short rotators and biceps, without definite sensory deficit. MRIs, plain X-rays, and electromyographies were examined supplementarily. Their mean age was 60.3 years old, range 40-75, 15 males and 4 females. Symptoms at the onset, the duration, and the self-evaluation of their present status were investigated. At the onset, disability of shoulder elevation without pain appeared in 10 patients. Eight patients were aware of their shoulder weakness with shoulder or neck pain. Nine patients obtained almost complete relief of symptoms within 3 months from the onset. Muscle weakness or shoulder pain had still remained in 4 patients without ADL disability. Two showed no recovery from pain and weakness. Patients having CSA are sometimes wrongly diagnosed as having shoulder disorder, because it shows slight sensory deficit. Confirmation of biceps weakness is useful in the differentiation of CSA from shoulder disorders.

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To clarify the anatomy of the long thoracic nerve (LTN) and functional anatomy of 3 parts of the serratus anterior muscle (SA) from innervations and the shape of each fiber. We collected the 10 shoulders of 5 cadavers (3 males and 2 females,average age 82,4 years old). The upper, middle, and lower parts of SA were classified according to the Eisler's definition. We observed which components from C4, C5, C6, and C7 innervated each part of the SA. The upper part was mainly innervated by C5 fiber and also C4, C6, or C7 fibers connected to the parts in 8 of 10 shoulders. The long thoracic nerve consisted of C6 and 7 fibers innervated middle and lower parts. The cross section area of the upper part was wider than those of other parts, and the upper part ran in the direction of the anterior compared to that of the middle part. The upper part of SA may be worked as the center of the scapula in an up and downward rotation. Degenerative change or sprain of cervical spine and direct trauma to the medial scalenus muscle may have caused damage of LTN and then dysfunction of the SA.

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We studied and compared the examinations of suprascapular nerve palsy in which we operated on whose symptoms were caused by a ganglion cyst and by trauma. The patients were 9 men we operated on them from 1996 to 2005. Their mean age was 37 years old. Their mean follow-up period was 25.4 months. 3 cases were caused by trauma, and 6 cases were caused by a ganglion cyst. The chief complaint was severe pain at rest for the trauma case, and dull pain on motion for the ganglion case. Weakness of external rotation was noted in all cases. Supraspinatus and infraspinatus muscle atrophy showed in all trauma cases. MRIs showed a ganglion cyst existed at the spinoglenoid notch in all ganglion cases. We recognized denervation in the electromyograms at the supra/infrasupinatus muscle for all trauma cases. We performed an arthroscopic decompression for the ganglion cases, and neurolysis of suprascapular nerve for the trauma cases. The suprascapular nerve was not ruptured and entrapped in the suprascapular notch. Previous pain had improved in all cases after the operation. In trauma cases, muscular atrophy remained in 2 cases. As a ganglion cyst existed at the spinoglenoid notch, we thought that their pain was weaker. In trauma cases, weakness of external rotation remained because the supraspinatus nerve was entrapped at the suprascapular notch and stretch for adduction at the trauma. A treatment policy was basically similar to a non-traumatic cases in a trauma cases, but we thought when severe pain remained, and conservative therapy did not succeed like this case, early operation should be done.

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Since frozen shoulder (adhesive capsulitis) is characterized by spontaneous recovery, no precise treatment strategy exists. Conservative therapy is available in the form of physical therapy, and injection therapy, and joint manipulation, release of the ligaments, and arthroscopic surgery are available as surgical therapies, but the time required for recovery varies considerably. Nevertheless, there have been very few reports on medication therapy. In this study we found that it was possible to obtain early symptom relief with oral steroid therapy. The criteria for inclusion in this study were absence of osteoarthritic changes or calcification on plain radiographs, absence of rotator cuff injury, including an incomplete rupture, on MR images, and a negative supraspinatus muscle (empty-can) test. There were 53 patients (30 males, 23 females), and their ages at the time of treatment ranged from 33 to 67 years old (mean: 55.6 years old). Complications consisted of diabetes mellitus in 2 patients, and hypertension in 7 patients. A single course of steroid therapy consisted of a total dose of 105 mg of prednisolone over approximately a 3-week period by the dose-tapering method. The number of courses varied with the degree of symptom relief, but the rest period between courses was always approximately 4 weeks. The results of treatment were assessed on the basis of the JOA score, but the principal items assessed were pain and range of motion. The evidence of inflammation of the shoulder joint before treatment was evaluated by gallium scintigraphy, was noted in 14 of the 17 patients. The ranges of motion before treatment were 102.8° of anterior elevation and 11.3° of external rotation, and internal rotation was at the buttocks in almost every case. However, after 1 course of treatment, anterior elevation was 136°, external rotation was 33.7°, and internal rotation was limited to the buttocks in only 6 cases. The results of oral steroid therapy for frozen shoulder (adhesive capsulitis) were highly satisfactory. However, sufficient care was required in explaining the method of administration in case side effects exist, such as the development of femoral head necrosis.

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Calcifying tendinitis is classified to 3 phases: acute, subacute and chronic, according to the severity and the period from the onset of the disease. Conservative treatment is usually effective in acute and subacute phases; calcification and symptoms disappear during the natural course of this disease. However, calcification does not disappear and chronic shoulder pain remains in chronic phases in some cases. Currently a novel technique: arthroscopic calcification removal was reported in some literature. The aim of this study was to evaluate the clinical results of arthroscopic calcification removal for calcifying tendinitis with a minimum follow-up of 6 months. We retrospectively evaluated 20 shoulders in 20 patients (10 males and 10 females), who were diagnosed as chronic phase calcifying tendinitis and received arthroscopic calcification removal. The average age at the time of the surgery was 59.8 years old(43-83 years old). The average post-surgical follow-up was 20.7 months (7-46 months). We examined calcification and rotator cuff disease with X-ray, 3D-CT and MRI. Clinical results were evaluated using the JOA scores. Active range of motion of flexion and abduction were also evaluated. The average active flexion improved from 148.5 degrees preoperatively to 159.0 and 167.5 degrees at 3 and 6 months follow-up respectively. The average active abduction improved from 134.5 degrees preoperatively to 151.5 and 160.0 degrees at 3 and 6 months follow-up respectively. The average JOA score improved from 64.4 points preoperatively to 86.9 and 93.9 points at 3 and 6 months follow-up respectively. Additional arthroscopic rotator cuff repair surgeries were performed in 10 cases. We observed a complete calcification removal in 19 of 20 cases (95%) and no recurrence of calcification during the follow-up period. Patients treated with arthroscopic calcification removal for calcifying tendinitis have showed excellent clinical outcomes at a minimum of 6 months follow-up.

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Shoulder pain induced by dialysis-related amyloidosis is one of the most frequent lesions that occur in long-term haemodialysis patients. We thought that the main cause of shoulder pain was the increase of subacromial pressure induced by the amyloid deposit in the subacromial bursa and rotator cuff, and have performed endoscopic coraco-acromial ligament release (ECLR) with a view of the decompression of the subacromial space. We considered pathogenesis of this lesion by investigating the course after ECLR over 5 years and comparing them with the preoperative image and clinical findings. 28 men (32 shoulders) and 40 women (56 shoulders) who had been having dialysis for an average of 18.7 years were operated on. ECLR was performed under local anesthesia in all cases. The follow-up mean period was 6.7years. We evaluated the results according to the JOA score and compared them with the ultrasonograpic changes. We also investigated the recurrent rate and additional operation. The average JOA improved from 65.3 to 88.7 at 1 month after operation, but became worse at the last follow up (80.6). The recurrent rate was 17.0%. Additional ECLR was needed in 6cases, open subacromial bursectomy in 2cases, arthriscopic synovectomy in 5 cases and arthroplasty in 2cases. ECLR was not effective in 8 cases. Cervical laminoplasty was required in 3 cases. Although the subacromial lesion is the main cause of the shoulder pain in long-term haemodialysis patients, attention to advanced shoulder arthropathy, recurrence and cervical lesions must be paid.

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We described the case of a massive rotator cuff tear treated by a reconstruction with fascia lata grafting and evaluated by a second-look arthroscopy. Case: A 56-year-old man who had been a manual laborer and lifted heavy objects for 30 years was referred to our clinic. He presented himself with a history of discomfort in the right shoulder associated with progressive pain and with a loss of motion. A physical examination confirmed that active motion was restricted to 90 degrees flexion and 60 degrees abduction. A Hawkins' impingement was present; a supraspinatus (SSP) test indicated weakness of the SSP. An MRI scan showed massive rotator cuff tears. Clinical results were evaluated using a Japanese Orthopaedic Association shoulder scoring system (JOA score) and the preoperative score was 41 points. Surgical treatment was performed with arthroscopic debridement for a partially torn long head of the biceps brachii, inflammatory synovial tissue and degenerative rotator cuff torn end with subacromial decompression. Arthroscopic evaluation revealed massive rotator cuff tears measured 40mm in width and 50mm in length; rotator cuff defect measured 20mm in width and 15mm in length and remained after sufficient debridement of the surrounding tissue around the torn tendon. Rotator cuff reconstruction with double folded fascia lata grafting for the defect was performed with 2 suture anchors. The JOA score had improved 81 and 87 points at 3 and 6 months follow up respectively. Active motion was recovered to 170 degrees flexion and 160 degrees abduction. A second-look arthroscopy evaluation revealed good continuity and integration between rotator cuff tendons and grafted fascia lata as well as fascia lata and the greater tuberosity with almost normal shoulder articulation. Our current second look evaluation indicated that fasia lata grafting might be one of the useful options for the reconstruction of massive rotator cuff tears.

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A 70-year-old man with a past history of pneumoconiosis underwent a surgery for the fracture of the distal end of the right clavicle with Kirschner wires and soft wire at a local hospital. He had sustained slight chest pain since 6 months after surgery and visited another hospital because his chest pain was aggravated about 2 months later. Radiographs and CTs showed the migration of the Kirschner wire, sticking into the trachea. He visited our hospital and the tip of the Kirschner wire was observed by a bronchoscopy. The migrated Kirschner wire was directly identified and removed through a right thoracotomy. The remaining Kirschner wires and soft wire were also removed from the clavicle. His postoperative course was uneventful. Perforation of the trachea by a migrated Kirschner wire is very unusual. In this case, pneumothorax did not occur when the migrated Kirschner wire perforated the pleura probably because of the pleural adhesion due to pneumoconiosis, causing only slight chest pain. The aggravation of chest pain was probably attributable to the perforation of the trachea by the further migrated Kirschner wire. When a Kirschner wire is used for fracture surgery, it should be inserted certainly into bone and its end should be bent sufficiently to prevent it from migrating.

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We reported on 2 cases of tuberculosis of the shoulder. [Case 1] A 76-year-old female who complained of right shoulder pain visited a neighborhood hospital. Since she was diagnosed with rotator cuff tear, rotator cuff repair was performed. In the 1-month postoperative period, however, wound separation began. With no treatment effects, the patient visited our department 1 year after the surgery. The surgery wound was found to have a fistula. X rays and MRIs showed a destructive change of the shoulder joint. Acid-fast bacillus culture for sputum and exudate exhibited the existence of tubercle bacillus. She was diagnosed with pulmonary tuberculosis and tuberculosis of the shoulder, and administration of antiphthisic was begun. Then, a lesion curettage was conducted, 5 months after the administration started. The patient showed no recurrence of this tuberculous disorder. [Case 2] An 81-year-old male who complained of right shoulder pain visited a neighborhood hospital. He was diagnosed with periarthritis scapulohumeralis and received conservative treatment. 4 months after the symptoms were found, he showed fistulation in the axillary region. According to Gaffky using exudate, viewing the results of Gaffkyl, he was diagnosed with tuberculosis of the shoulder, and administration of antiphthisic was begun. Lesion curettage was conducted 4 months after the administration was begun. The patient showed no recurrence In the above 2 cases of tuberculosis of the shoulder, the initial diagnosis was difficult and a lengthy period of time was required to confirm symptom appearance and establish proper diagnosis. Antiphthisic administration and open surgery prevented further infection.

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