Katakansetsu

Degenrative diseases

The Stress Distribution Patterns at the Glenoid Cavity in Patients with Primary Shoulder Osteoarthritis Measured by CT Osteoabsorptiometry

Hiroshi YAMAGUCHI, Fuminori KANAYA, Naoki SUENAGA, Naomi OIZUMI, Noria ...

2011 Volume 35 Issue 3 Pages 919-921
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.919

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We often observe the lower joint space narrowing in primary shoulder osteoarthritis. However, previous studies reported stress distribution was found in center, center-posterior and posterior directions in primary shoulder osteoarthritis. CT osteoabsorptiometry(CTOAM) has been used to study the stress distribution changes of the glenoid and coracoacromial arch in various types of pathologic shoulders. There are few studies about primary shoulder osteoarthritis measured by CTOAM. The purposes of this study were to evaluate stress distribution of the glenoid cavity in primary shoulder osteoarthritis using CTOAM and to compare stress distribution pattern of primary shoulder osteoarthritis and asymptomatic shoulder. 27 shoulders in 24 patients with primary shoulder osteoarthritis and 27shoulders in 14 patients with asymptomatic shoulder were analyzed for this study. Results showed 6 patterns (Central; 33%, Anterior-posteroir; 22%, Anterior; 15%, Inferior; 11%, Diffused; 11%, Central-posterior; 7%) of stress distribution were observed in primary shoulder osteoarthritis, and 4 patterns (Anterior-posteroir; 44%, Anterior-center-posteroir; 38%, Anterior-inferior; 11%, Anterior; 7%) were observed in asymptomatic shoulders. Stress distribution at the glenoid cavity of primary shoulder osteoarthritis involved characteristic shift (Inferior, Diffused), which were compared to asymptomatic shoulder and previous reported cuff tear arthropathy. These results may show different pathologic change involved in primary shoulder osteoarthritis. We believe the results of this study will provide useful information to understand the pathogenesis of primary shoulder osteoarthritis.

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Clinical Outcome of Arthroscopic Treatment for
Hemodialytic Shoulders

Tomoya MANAKA, Yoichi ITO, Isshin MATSUMOTO, Naoto OEBISU, Nobuyuki NA ...

2011 Volume 35 Issue 3 Pages 923-926
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.923

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Hemodialytic shoulder is a common shoulder disorder with severe shoulder pain in long-term hemodialysis patients. Shoulder arthroscopic surgeries have recently developed, though few reports about the effectiveness of arthroscopic surgeries for hemodialytic shoulders are reported in the literature. The aim of this study was to evaluate clinical results of arthroscopic treatment for hemodialytic shoulders with a minimum follow-up of 6 months. We retrospectively evaluated 11 shoulders in 8 patients, who were diagnosed as having hemodialytic shoulders and who received arthroscopic treatment. Average age at the time of surgery was 60.3 years old (range; 49-64 years). Average post-surgical follow-up was 29.8 months (range; 6-58 months). Arthroscopic surgeries included debridement in 11 shoulders, subacromial decompression in 10 shoulders and rotator cuff repair in 4 shoulders. Clinical features such as hemodialysis duration and hemodialysis pain were evaluated. Clinical results were evaluated using the Japanese Orthopaedic Association shoulder scoring system (JOA score). Average duration of hemodialysis was 21.8 years (range; 4-31 years) and over 20 years of long-term duration were observed in 8 cases. Hemodialysis pain was observed in all cases preoperatively. The average JOA score improved from 53.6 points preoperatively to 79.5 and 86.0 points at 3 and 6 months follow-up respectively. Patients treated with arthroscopic surgeries for hemodialytic shoulders showed excellent clinical outcome at a minimum of 6 months follow-up.

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Inflammatory disease

Effects of Biologics on Shoulder Joints in Patients
with Rheumatoid Arthritis

Kazuhito SUGIMORI

2011 Volume 35 Issue 3 Pages 927-930
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.927

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The assessment of joint damage in rheumatoid arthritis (RA) during biologic therapies has been mainly restricted to small joints in hands and feet. On the other hand, there are few reports about the effects of biologics on shoulder joints in RA. The purpose of this study is to elucidate the joint damage of the shoulder and the relationship of clinical effects. Nineteen patients (2 males and 17 females, mean age of 60.0 years old) were evaluated at baseline and 2 years after biologics therapies. Clinical responses at 2 years were defined according to EULAR response criteria. The structural damage in shoulder joints was assessed using the Larsen scoring method. The medial displacement index (MI) was obtained by dividing the distance between the centre of the humeral head and the glenoid surface by the radius of the humeral head (R). The upward migration index (UI) was obtained by dividing the distance between the centre of the humeral head and the central point of the subacromial surface by R. Four of 28 shoulders of Larsen grade 0-II showed progression of each grade. Whereas 5 of 8 shoulders of Larsen III-V showed apparent progression. There was no relationship between progression of Larsen grade and clinical response. In the early grade, less than Larsen grade II, it is supposed that the progression of shoulder joint damage is inhibited.

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The Clinical Results for Pyogenic Arthritis of the Shoulder
- Report of 5 Cases -

Osamu ITO

2011 Volume 35 Issue 3 Pages 931-934
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.931

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Pyogenic arthritis of the shoulder is considered to be relatively rare. We treated 5 patients with pyogenic arthritis of the shoulder from 1996 to 2009. There were 5 males, aged from 16 to 80 years old, with a mean age of 69.5 years old. The causes of infection were intra-articular injection in 2 cases, infection from different organisms in 2 cases, and unknown in one case. Staphylococcus aureus was cultured in all 5 cases. The mean interval between onset and surgical treatment was 6 days. Open debridement with suction drainage were performed in 3 cases, one case with massive cuff tear, one with phlegmon of the ipsilateral upper extremity, and one treated by another doctor, and arthroscopic debridement with suction drainage in 2 cases.Initial surgery, in one case treated with open debridement had failed initial surgery, and so required revision surgery, arthroscopic debridement with irrigation. The follow-up period averaged 10 months. There were no recurrences, even in the one case of revision surgery. In radiographic finding, 2 cases revealed osteolytic change on the greater tuberosity but remained stationary at the final follow-up.
There were recently some reports in which arthroscopic debridement was a useful method for the treatment of pyogenic arthritis of the shoulder.
Likewise 3 of our cases were treated successfully. Although irrigation was initially performed in all cases of pyogenic arthritis we now believe that irrigation is indicated in patients with osteoarthritis or with postoperative infection, or whose causative organism is, MRSA or streptococcus pneumoniae. We emphasize the importance of early diagnosis and treatment.

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Miscellaneous lesions of the shoulder

The Relationship between Range of Motion of Shoulder and Medial Elbow Laxity in High School Baseball Players

Mikio HARADA, Nariyuki MURA, Junya SASAKI, Masahiro MARUYAMA, Toshihik ...

2011 Volume 35 Issue 3 Pages 935-938
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.935

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The aim of this study was to investigate the relationship between ROM of shoulder and medial elbow laxity in high school baseball players.
One hundred and five high school baseball players aged 15-17 years old underwent medical examination after fall baseball season had ended. Passive ROM of external rotation (ER) and internal rotation (IR) of the shoulder was measured bilaterally. Ultrasonography of the medial aspects of both elbows was performed to assess medial elbow laxity. Using the ultrasonograms, the increase of medial elbow joint space on the throwing side (Increase-MEj) was calculated, compared to the non-throwing side. The ROM of ER was 128° on the throwing side and 115° on the non-throwing side. The ROM of IR was 45° on the throwing side and 65° on the non-throwing side. The mean increase-MEj was 1.0mm. 11 subjects had the increase-MEj of 2.5mm or more (laxity group), and 94 had the increase-MEj of < 2.5 mm (normal group). In the laxity group, the ROM of ER was 136° on the throwing side, and that in the normal group, the corresponding ROM was 128°. Compared with the normal group, the ROM of ER in the laxity group was significantly increased. There was no difference in the ROM of IR between the laxity group and the normal group.
The ROM of external rotation of the shoulder could be correlated with medial elbow laxity in high school baseball players.

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Development of Dynamic Model for Throwing Shoulder Injury
∼ Simulations of Stress Distribution in Gleno-humeral Joint at Pitching Motion ∼

Takeo ISHII, Shumpei MIYAKAWA

2011 Volume 35 Issue 3 Pages 939-943
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.939

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There were two purposes for this study. One was to identify risk-factors on dynamics which affected humeral head abnormality on MRI using logistic regression analysis. The other was to simulate stress distribution in humeral head at maximum external rotation (MER) of throwing phase using Finite Element Method analysis (FEM). Then we evaluated the validity of the simulation using MRI findings of humeral head abnormality. The subjects were 18 asymptomatic collegiate baseball players who took part in both MRI and pitching motion analysis. The shoulder joint reaction force was calculated using multi-body dynamics analysis with musculoskeletal model analyzed from foot contact to ball release of pitching motion. We did logistic regression analysis to identify whether the force was a risk-factor or not. As a result, the risk-factor of humeral head abnormality on dynamics was the shoulder joint reaction force (shearing force) at the acceleration phase. We simulated the stress distribution in the humeral head at MER using FEM model and input the shoulder reaction force. Stress distribution in the simulation was almost the same as that of humeral head abnormality in MRI. This simulation is expected to be a useful predictor of the humeral head abnormality caused by internal impingement of throwing shoulder injury.

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Anterosuperior Impingement in Throwing Injury of the Shoulder

Katsumasa SUGIMOTO, Hideyuki GOTO, Masato YOSHIDA, Atsushi TSUCHIYA, T ...

2011 Volume 35 Issue 3 Pages 945-948
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.945

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In throwing injury of the shoulder, the patient shows restrictions of flexion and internal rotation. However, the precise mechanisms remain controversial. Gerber et al. described anterosuperior impingement (ASI) as a form of intraarticular impingement in 1999. The purpose of this study was to clarify relationships between throwing injury and ASI. Subjects comprised of 22 patients (mean age, 23.8 years old; range, 16-37 years; 20 men, 2 women) who underwent surgery between 2007 and 2010 for treatment of injuries causing throwing disturbance. Clinical symptoms (range of motion, instability, etc.) were checked preoperatively. Intraoperatively, we checked ASI of all cases in flexion and internal rotation positions. ASI was present preoperatively in 19 / 22 cases and GIRD (glenohumeral internal rotation deficit) existed in 22 / 22 cases. But both diminished postoperatively after reducing anterior instability by reinforcement of the MGHL. We considered that some relationship might exist between ASI and anterior instability, and GIRD resulting from throwing injury. Restrictions of flexion and internal rotation may occur in the shoulder after throwing injury due to ASI.

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Shoulder Rotational Muscle Power Recovery after Arthroscopic Repair of Type II SLAP Lesion

Masatoshi AMAKO, Hiroshi ARINO, Yoshifumi TSUDA, Koji YAMAMOTO, Koichi ...

2011 Volume 35 Issue 3 Pages 949-952
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.949

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The purpose of this study was to evaluate shoulder muscle power recovery after arthroscopic labrum repair for type II SLAP lesion. Nineteen patients with type II SLAP lesion were evaluated for shoulder rotational muscle strength before and after arthroscopic labrum repair using suture anchors. The peak torque of both shoulders during isokinetic concentric muscle contraction was measured under the condition of 60, 180, 300 and 450 degrees/sec. using Biodex dynamometer at before and 3, 4.5, 6, 9, and 12 months after the surgery. The peak torque ratio was calculated. The peak torque ratio during external rotation was recovered to the preoperative level by 4.5 months, and returned to the contra-lateral level by 6 months. There was no difference of the peak torque recovery among the motion speed conditions. The peak torque ratio of internal rotation was recovered to the preoperative level by 3 months, and increased to the contra-lateral level by 4.5 months. The peak torque ratio in higher speed conditions was recovered earlier than that in lower speed conditions. The rotational muscle strength was rapidly recovered after arthroscopic labrum repair for SLAP lesion. The muscle strength recovery in external rotation was retarded compared to that in internal rotation. The muscle strength under the high speed conditions was considered to be reduced for athletes with throwing shoulder injury, however, our cases with SLAP lesion recovered well under the high speed conditions. They obtained sufficient muscle balance by 6 months, and could resume to the high-level throwing activity sports.

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The Figure of Internal Impingement Changes by Pitching Counts
- Study by Open MRI -

Atsushi TASAKI, Wataru MORITA, Eishi KURODA, Yoshimitsu HOSHIKAWA, Tai ...

2011 Volume 35 Issue 3 Pages 953-956
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.953

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Internal impingement in the late cocking phase (LCP) is a physiological phenomenon but leads to pain and tissue trauma by excessive burden. We studied the change in the figure of internal impingement at LCP by pitching counts using open MRI. Ten high-school pitchers with no history of shoulder disorder were studied. ROM was measured before and after 100 pitches in a bull-pen. Oblique coronal slices of MRI were taken by open MRI with the shoulder in ABER position to simulate LCP, before and after the burden. The figure of the internal impingement was evaluated by a special MRI calculator (image J) by a radiologist. After pitching, the range of external rotation increased, and internal rotation decreased significantly from 143.0° to 146.7°, 51.0° to 45.6°, respectively. The restaged LCP position in the MRI was 131.4° degrees flexion, 117.0° external rotation, 14.6° horizontal abduction on average. All cases showed internal impingement before and after the exercise. The measurement from the greater tubercle, vertical length from the articular level of the rotator cuff to the deepest part of the impinged cuff increased significantly from 10.6 to 12.8mm and 5.0 to 6.27mm, respectively. The cuff had intervened in between the greater tubercle and the glenoid forming a triangular shape and the area had increased significantly from 34.3 to 42.7mm². Considering the risk of pitching injury by number of pitches, the change of the figure of internal impingement at ABER simulating LCP showed by our study is an important phenomenon for the understanding of pitching injuries.

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Rotator Cuff Repair for Articular-side Partial Rotator Cuff Tear (APRCT) in Painful Shoulders of Overhead Athletes.: Open Versus Arthroscopic Technique

Taishi UEHARA, Daisuke MAKIUCHI, Naoya NISHINAKA, Suguru NAGAI, Kazuhi ...

2011 Volume 35 Issue 3 Pages 957-960
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.957

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The purpose of this study was to compare the clinical results of open rotator cuff (RC) repair (open group) and arthroscopic RC repair (arthroscopic group) for APRCT in painful shoulders of overhead athletes. We retrospectively studied 8 shoulders in the open group and 4 shoulders in the arthroscopic group. The average age at the time of surgery was 23.0 years in the open group and 24.0 years in the arthroscopic group. Seven baseball players and 1 volleyball player were included in the open group and 3 baseball players and 1 volleyball player were included in the arthroscopic group. The average follow-up was 22.3 months in the open group and 21.3 months in the arthroscopic group. We evaluated clinical outcome using the JSS shoulder sports score (JSS-SSS), return to sports activities and progress of range of motion. The average JSS-SSS improved from 19.0 preoperatively to 65.6 postoperatively in the open group and 31.0 preoperatively to 68.8 postoperatively in the arthroscopic group. The period until resumption of throwing activities after surgery was 8.1 months in the open group and 5.0 months in the arthroscopic group (p=0.0025). Six cases (75.0%) in the open group and 3 cases (75.0%) in the arthroscopic group returned to their preoperative sports activities on average 10.3 and 13.7 months postoperatively respectively. The restoration of range of motion in flexion at 9 months after surgery in the arthroscopic group was significantly better than in the open group (p=0.0479). The clinical results of both groups were mostly satisfactory. However it took a long time for the open group to return to their previous sports activities compared with the arthroscopic debridement group.

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MRI of Anterosuperior Corner Injury in the Shoulder

Masahito YOSHIDA, Hideyuki GOTO, Kaneaki TAWADA, Katsumasa SUGIMOTO, A ...

2011 Volume 35 Issue 3 Pages 961-963
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.961

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Shoulder pain and injuries are common in athletes. MRI is well suited to evaluate soft tissue of the shoulder and plays an important role for screening. The purpose of this study was to evaluate findings of non-contrast MR images in athletes who were treated for anterosuperior corner injury (SLAP lesion, middle glenohumeral ligament (MGHL) injury, etc) confirmed at arthroscopy.
We treated 21 athletes, (16 men, 5 women) with a clinical diagnosis of SLAP lesion and tear or elongation of MGHL, using suture anchor from 2008 to 2010. In this study, preoperative non-contrast MR images of these patients were reviewed retrospectively. The evaluation of rotator cuff , and long head of the biceps brachii (LHB) were included in the assessment of images. The mean age of subjects was 26.3 years old ranging from 17 to 41. Acute traumatic cases were excluded in the present study. High signal intensity of T1-weighted images was demonstrated around the rotator interval in 19 cases (90.5%). In addition, High signal intensity of T2-weighted images was found in 16 cases (76.2%) at the same area.
Signal intensity of MR images at the anterosuperior corner may show some correlation with the injury of MGHL, SLAP lesion, the inflammation or tear of anterior-superior capsule and the synovium of the rotator interval. Additional work is necessary to further define objective radiographic evidence.

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Sensory Innervation of Rat Contracture of the Shoulder Model

Nobuyasu OCHIAI, Tomonori KENMOKU, Hironori YAMAZAKI, Takashi SAISU, K ...

2011 Volume 35 Issue 3 Pages 965-969
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.965

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The purpose of this study was to evaluate the dorsal root ganglion (DR:kG) neurons which innervate the glenohumeral joint (GHJ) and subacromial bursa (SAB) in the rat contracture model. The contracture models were made by tying the humerus and scapula using 2-0 Fiber wire. First, contracture model was confirmed using X-ray 8 weeks after the operation. Abduction and total arc of the rotation were statistically significantly decreased in the contracture group. Two kinds of neurotracers such as fluoro-gold (FG) and dioctadecyl-tetramethyl-indocarbocyanine-perchlorate (DiI) were used to detect GHJ and SAB separately 8 weeks after the first operation. FGs were injected into the GHJ and DiI were injected into the SAB. Seven days after, DRGs were harvested between C1 and T1. Immunohistochemistry using calcitonin gene-related peptide was performed and the percentage of FG labeled CGRP-immunoreactive (ir) neurons in the total number of FG-labeled neurons and the percentage of DiI-labeled, CGRP-ir neurons in the total number of DiI-labeled neurons were evaluated. CGRP-ir DRG neurons were found to be 26.6% in the sham group and 54.4% in the contracture group of the total FG-labeled neurons. DiI-labeled, CGRP-ir DRG neurons were found to be 33.5% in the sham group and 51.7% in the contracture group of the total DiI-labeled neurons. The percentage of the CGRP-ir DRG neurons was significantly higher in the contracture group both in GHJ and SAB. These data demonstrated that the painful conditioned in shoulder contracture may be induced by the higher rate of existence of CGRP expression in DRG neurons.

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Improvement of Range of Motion by Arthroscopic Capsular Release for the Treatment of the Frozen Shoulder

Hideyuki GOTO, Osamu HORIUCHI, Kaneaki TAWADA, Masahito YOSHIDA, Yasuh ...

2011 Volume 35 Issue 3 Pages 971-974
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.971

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The purpose of this study was to report the clinical outcomes and improvement of range of motion by arthroscopic capsular release for the treatment of the frozen shoulder. In this study, 100 cases of 100 shoulders including 21 cases of traumatic frozen shoulder due to the fracture (10 cases), dislocation of the acromioclavicular joint (2 cases) and rotator cuff tear (6 cases) and others (3 cases) and 79 cases of non-traumatic frozen shoulder due to calcium deposit (7 cases), atraumatic rotator cuff tear (23 cases) and idiopathic frozen shoulder (49 cases). The mean age of all cases was 55.4 years old ranging from 33 to 78 years old. The procedure was combined with arthroscopic capsular release and manipulation with additional procedure such as resection of the calcium deposit and rotator cuff repair. At a mean follow-up of 14 months, the clinical results of were evaluated by means of the JSS scores. JSS scores were improved from 58 points preoperatively to 95 points postoperatively. Pre and postoperative range of motion of flexion, abduction, external rotation and internal rotation was also investigated and good improvement has been confirmed at the final follow up. In conclusion, the present study shows that arthroscopic capsular release for the treatment of frozen shoulder had favorable clinical results.

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Primary Treatment of Frozen Shoulder

Raita NAGASAWA

2011 Volume 35 Issue 3 Pages 975-978
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.975

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Patients with frozen shoulder are suffering from their shoulder pain at night and resting time in activity of daily living. We had used cortical hormones (steroid) for those patients. The purpose of this study was to evaluate the effectiveness of an intra-articular injection and oral medicines of cortical hormones.
Materials and methods: From December 2008 to August 2010, there were 50 shoulders, 45 patients, average age was 59 years old, female 39 shoulders, male 11 shoulders. We administered an injection of triamcinolone acetonide or dexamethasone sodium phosphate into the gleno-humeral joint. We also prescribed prednisolone and NSAIDs for the inflammation. We evaluated the clinical results by visual analogue scale and JOA score.
Results: After the treatment, all outcome measurements had shown significant improvement. Mean VAS pain score was 7.0 at the first assessment and 0.9 at the last assessment. We had good improvement of JOA score from 47.5 points to 83.1 points. The treatment using cortical hormones showed significant improvement of shoulder joint contracture. These results suggested our treatment was effective in the reduction of shoulder pain and additional physical exercise could increase joint range of motion.

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Clinical Outcomes of Arthroscopic Surgery
for Shoulder Joint Contracture

Koushirou IMAI

2011 Volume 35 Issue 3 Pages 979-981
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.979

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Here we report clinical outcomes of cases of arthroscopic surgery including those complicated by diabetes mellitus. Arthroscopic surgery was performed on 13 shoulders of 13 patients (seven men, six women, six patients with complications of diabetes mellitus) with primary contracture that had not improved with conservative therapy performed at our hospital for more than three months. Postoperative clinical outcomes were measured using JOA score. The mean JOA scores were 51.9 in the non-diabetes group (group A) and 52.8 in the diabetes group (group B) preoperatively, and 92.9 in group A and 83.7 in group B postoperatively. The largest difference between groups A and B was in range of motion. Many clinicians may have seen that shoulder joint contracture is often refractory in patients with the complication of diabetes mellitus. Although the joint capsule was removed in the same manner, the range of motion in group B was more limited than that in group A under anesthesia, resulting in a smaller range of motion in group B at the final follow-up after surgery. This was attributed to contraction of not only the glenohumeral joint but also the scapulothoracic joint and others in group B. It was thought that a movable decrease of the sternoclavicular joint strongly took part. However, considering a marked improvement in pain score of JOA measured postoperatively, surgery may be adequately effective in group B also. The clinical outcomes after arthroscopic surgery were favorable in cases with contraction that had not been improved with conservative therapy.

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MRI of the Patients with Atraumatic Shoulder Pain

Masahito YOSHIDA, Hideyuki GOTO, Kaneaki TAWADA, Katsumasa SUGIMOTO, A ...

2011 Volume 35 Issue 3 Pages 983-986
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.983

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The continuation of conservative therapy was frequently seen in many patients with chronic shoulder pain without MR images. The purpose of this study is to investigate signs of non-contrast MR images in patients who have atraumatic shoulder pain.
(MATERIALS AND METHODS) In this study, the MR images of 56 shoulders in 56 patients were retrospectively assessed from March 2006 to September 2009. The mean age of subjects was 55.2 years old ranging from 13 to 86. Traumatic cases were excluded in the present study. MR studies were assessed for the presence, location (supraspinatus, infraspinatus, and subscapularis tendon), and size of rotator cuff tear.
The change of signal intensity at the bursa, the long head of biceps brachii (LHB), the labrum and other associated lesions were also evaluated on the images. One or more associated positive signs were identified in 89% of all cases. Rotator cuff tear were present in 44% (n=24) of cases. Partial-thickness tear (n=11), small tear (n=9), moderate tear (n=1) and massive tear (n=2) were included in these cases. Associated findings were identified, including tear (n=1), subluxation (n=1), and effusion (n=8) of LHB and effusion of subacromion (n=30), and subcoracoid (n=4). A labrum tear was also seen in 7 cases. Patients with atraumatic shoulder pain involved some positive signs of MRI in 89% of this study. And rotator cuff tear was included in 44%. MRI may permit more specific diagnosis in patients with atraumatic shoulder pain.

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Treatment

CT Evaluation of Pegged Glenoid Component with the 3^rd Generation Total Shoulder Arthroplasty

Daisuke MOMMA, Tadanao FUNAKOSHI, Naoki SUENAGA, Naomi OIZUMI

2011 Volume 35 Issue 3 Pages 987-990
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.987

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Although total shoulder arthroplasty (TSA) has been demonstrated to be an effective treatment for osteoarthritis (OA) and rheumatoid arthritis (RA), loosening of the glenoid component has been reported as a major complication. A previous report indicated that loosening of keeled component occurred more frequently compared to pegged component. The purpose of this study was to investigate the CT evaluation of pegged glenoid with the 3rd generation TSA. Seventeen shoulders were treated by pegged glenoid with the 3rd generation TSA, including eight RA, seven OA, and two OA after necrosis. The mean age was 62 years old (range 49 to 78). Radiolucent line or loosening was evaluated with Yian' CT score. No additional operations or obvious loosening of glenoid component were found. Total CT score was 3.2 points. There was no significant difference of score between RA; 3.6 (Range 2 ∼ 6 ) and OA; 2.8 (Range 0 ∼ 5 ). Compared to previous study, the glenoid component could be more stable as the number of peg increased. Our results were similar to the previous study. Better results would be associated with patient selection, cementing technique, and implant design. But we need more cases and long term follow-up.

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Outcomes of Extended Head Hemiarthroplasty for
Cuff Tear Arthropathy

Satoshi IWASHITA, Hiroshi HASHIGUCHI, Hiromoto ITO

2011 Volume 35 Issue 3 Pages 991-993
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.991

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The purpose of this study was to evaluate clinical outcomes of extended head hemiarthroplasty for cuff tear arthropathy (CTA). Five patients with cuff tear arthropathy, whose average age was 70.0 years old, were the subjects of this study. There were 4 female and 1 male. On the types of CTA according to Seebauer's classification, 1-a was observed in one patient, 2-a in two patients, and 2-b in one patient. All patients were treated with Depuy-Mitek Advantage Shoulder System with extended head. Humeral stem was fixed using bone cement in all of the patients. Clinical outcomes were evaluated on the basis of the JOA score and postoperative X-ray findings. The average follow-up period was 9.5 months. The average JOA score improved significantly from 58.8 points preoperatively to 80.8 points postoperatively. Regarding the shoulder range of motion, abduction improved from 111° preoperatively to 126° postoperatively, flexion from 110° to 118° and external rotation from 31° to 41°. There was no significant improvement of muscle strength around the shoulder. Loosening of the humeral stem and late infection were not observed at the final follow-up. This study suggests that hemiarthroplasty with extended head is a definite procedure to obtain satisfactory outcomes. However, the procedure may provide poor outcomes to some patients with motor weakness. Therefore, indication of hemiarthroplasty with extended head should be treated with caution in patients with motor weakness.

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Second Report of Shoulder Virtual Reality Arthroscopic Trainer

Hiroshi NOGUCHI, Masataka SAKANE

2011 Volume 35 Issue 3 Pages 995-1000
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.995

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Recently, shoulder arthroscopic surgery has been increasing. Due to the high degree of difficulty, technical mastery of the surgery takes experience of many cases and a long time. We had reported that, in Shoulder Virtual Reality Arthroscopic Trainer (VRAT), the shoulder surgeon's time spent for probing task was shorter than those of residents and medical students. In this study, we evaluated whether any level of arthroscopic experience correlated to the result of VRAT or not, using probing task and more difficult anchoring task, and spreading the subjects from novice to expert: total=53 orthopaedic surgeons, and we examined the validity of VRAT with questionnaires. Probe task: experience of under 500, the number of shoulder arthroscopic surgeries experience was correlated with Global Score (p=0.026, CR=0.376), Time(p=0.048, CR=-0.332), and Covered Distance: Camera (p=0.040, CR=-0.344), statistically. In the case of experience of over 500, that meant expert, no correlation was found between experienced number and any metric. Anchor Task: Experience of under 500, the experienced number was correlated with Global Score (p=0.019, CR=0.396) and Maximum distance to tear (p=0.004, CR=-0.479), statistically. Among experts, there was no correlation between experienced number of surgeries and any metric. We recognized VRAT could evaluate the level of shoulder arthroscopic skill from novice to advanced, but couldn't distinguish expert from advanced. We think another (more difficult) task is required to determine the difference of technical level in expert, or there is a plateau of learning curve about of experience 500 cases. Questionnaires showed that VRAT was very useful or useful for all from inexperienced to intermediate and advanced, but not necessarily so for the expert.
We think that VRAT would help improvement of arthroscopy technique and reduce the learning curve, so it would improve patient safety in the future, if it were established as the arthroscopy education system.

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Case reports

A Case of Revision Surgery for the Loosening
of the Total Shoulder Arthroplasty

Etsuko MATSUMURA, Teruhiko NAKAGAWA, Tetsuya SATO, Yoshihiko MATSUYAMA ...

2011 Volume 35 Issue 3 Pages 1001-1003
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1001

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We performed a revision surgery for the loosening of the total shoulder arthroplasty and achieved good result. A 63 years old man visited our hospital with pain in his operated shoulder which had gotten worse. He was diagnosed with humeral head necrosis, and had total shoulder arthroplasty performed seventeen yeakrs ago. The findings of the first visit was tenderness in right upper arm . The range of motion (ROM) was 65° for active elevation(passive110°), external rotation 45°(90°) Internal rotation Th7 (Th7) Plain X-ray and CT showed the distal tip of the humeral shaft component protruded from the humerus, and thinning of posterior glenoid wall. We performed revision surgery after one month at first visit. The humeral shaft component was unstable and removed easily. We performed tri-cortical iliac bone graft to reconstruct the glenoid surface. Hydroxy apatite block was pushed into the glenoid cavity space. Humeral shaft component replacement with cement fixation was done. At 4.5years after the operation, his shoulder had no pain, The range of motion of his shoulder improved. In x-ray and CT findings good joint congruently was observed.

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The Treatment for Dislocation of the Shoulder with Glenoid Fractures Repaired by N-H method

Takanori OI, Hiroki NINOMIYA, Narikazu TOYOKAWA, Kazuki GOTO, Masahiko ...

2011 Volume 35 Issue 3 Pages 1005-1007
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1005

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A case of the treatment for dislocation of the shoulder with glenoid fractures repaired by N-H method is reported here. The patient was a 34-year-old man who injured his shoulder when he fell down while snowboarding. He reduced his shoulder by himself. Next day he visited our outpatient clinic and the roentgenograms showed the glenoid fracture and greater tuberosity fracture. In CT, anterior glenoid fracture was large of which the body occupied 22% of that (Hitachi medico H-premium). The greater tuberosity fracture had no displacement. Surgery was carried out to remove the patient's suffering. Anterior and anteroinferior instability was confirmed. EUA Arthroscopic examination revealed labrum tear from 7 to 12 o'clock, ruptured MGHL, the elongated joint capsule, and AIGHL as the diagnosis in CT. N-H method was performed. The findings obtained during the operation were similarly to those mentioned. After operation, to gain a normal ROM and sufficient muscle strength, passive, active, and resistant exercises were started after three weeks. Postoperative 4months, the union of the glenoid fracture was completed in CT. Because the N-H method aimed at the reconstruction of the elongated anteroinferior capsule supplemented by a double breasting of the anterior wall of the joint using the subscapularis tendon, fracture of the body could gain stability and union. It may be difficult to gain the same result with arthroscope unless using screw or anchor. The N-H method is useful for fracture-dislocations of the shoulder without internal fixation to gain stability and union.

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A Case Considered to Be Pyomyosis whose Symptoms were Shown Only in Infraspinatus of the Shoulder

Hirokazu KOBAYASHI

2011 Volume 35 Issue 3 Pages 1009-1012
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1009

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Although cellulitis is a well known disease concerned well, it may suffer from the misdiagnosis with infection or necrotizing fasciitis. We reported on a case of considered to be pyomyosis whose symptoms were shown only in infraspinatus. A 58-years old man who complained of right shoulder pain and limited of ROM. His clinical history showed that he had hit his right shoulder on a kitchen shelf at his house, and recieved an abrasion on the outside of his right shoulder. The next day, he had right shoulder pain and limited ROM. However, NSAIDs was not effective. One week later, the right shoulder was not swollen and a feeling of heat found at the time of the first medical examination was not present. Blood biochemistry and picture inspection were carried out. MRI showed the presence of edema of only infraspinatus. We diagnosed this case as pyomyosis. The treatment carried out using an antibiotic and NSAIDs medication. A feature of this case was that MRI showed the state of edema of only the infraspinatus and the other muscles were considered of the usual intensity, and the shoulder was not swollen and did not feel hot.

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Glenohumeral Osteoarthritis After Arthroscopic Bankart Repair
- A Case Report -

Toru YOSHIOKA, Youichi MURATA, Junichi HAMAWAKI, Kazuhiko KIKUGAWA, No ...

2011 Volume 35 Issue 3 Pages 1013-1016
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1013

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We experienced a case of glenohumeral osteoarthritis following arthroscopic Bankart repair. A 22-year old man came to our hospital with a complaint of recurrent anterior subluxation of his left shoulder. He received arthroscopic Bankart repair using 5 absorbable suture anchors and 2 Fiberwires on each anchor and started ROM exercise after 3 weeks immobilization. At 18 months after the surgery, X-rays, CT and MRI exhibited joint space narrowing, spur formation and cystic lesion, indicating glenohumeral joint osteoarthritis. At 32 months after the surgery, arthroscopic exmination indicated that abrasion powders of the Fiberwires were observed in the cystic lesion of the joint, and arthroscopical intervention was performed including resection of the powders and curettage of the cyst. At 6 months after the repeat surgery, this patient complained of no symptoms and his shoulder had good stability. CT also demonstrated the cystic lesion had improved. In this case, the abrasion powder of Fiberwire suture might have induced inflammatory arthritis, subsequently become osteoarthritis, since the powders were observed in the cystic lesion and resection of the powders improved the cystic lesion. Previous papers have reported that the bioabsorbable anchor caused osteolysis and arthropathy, but there have been no studies that show Fiberwire suture alone caused osteoarthritis. Our case suggested that Fiberwire suture also might cause osteoarthritis. We reported a case of glenohumeral osteoarthritis following arthroscopic Bankart repair. The abrasion powders of Fiberwires might cause osteoarthritis.

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Rapidly Progressed Osteoarthritis of the Shoulder after Arthroscopic Stabilization in an Elderly Patient: A Case Report

Hironori MANABE, Hiroyuki SUGAYA, Norimasa TAKAHASHI, Nobuaki KAWAI, H ...

2011 Volume 35 Issue 3 Pages 1017-1020
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1017

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Rotator cuff tear is often combined with Bankart lesion in elderly patients with recurrent shoulder instability. Recently, several reports describe the advantage in repairing both Bankart lesion and rotator cuff tear for recurrent shoulder instability in elderly patients. In this article, we report a case of rapid shoulder osteoarthritis after combined arthroscopic Bankart and rotator cuff repair. A 79-year-old female suffered first shoulder dislocation 10 years ago, after that; she dislocated her shoulder 3 times. In December 2008, she visited our hospital complaining about her unstable shoulder. She also complained of pain during shoulder motion and night pain. Imaging study demonstrated Bankart and Hill-Sachs lesion associated with massive rotator cuff tear with joint effusion. We performed arthroscopic rotator cuff repair in addition to Bankart repair. After surgery, she complained of prolonged night and rest pain, and joint effusion. Therefore, we performed joint fluid removal and steroid injection periodically. Four months after surgery, X-ray demonstrated rapid progression of shoulder osteoarthritis associated with joint effusion. Therefore, we performed arthroscopic debridement at 5 months after surgery, after that progression of osteoarthritis and pain subsided gradually. Although massive rotator cuff tear is frequently associated with traumatic shoulder instability in the elderly, rotator cuff repair in addition to Bankart repair may cause rapid progression of osteoarthritis due to high intraarticular pressure after repair. Surgeons should be careful when they treat traumatic shoulder instability associated with both Bankart lesion and chronic massive rotator cuff tear in the elderly.

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Two Cases of the Any Joint Dislocations Following the Operation for Atraumatic Shoulder Instability

Shuhei OGINO, Shigehito KURODA, Noriyuki ISHIGE, Ryo MURATA, Kimiko MA ...

2011 Volume 35 Issue 3 Pages 1021-1023
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1021

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We describe two cases of recurrence of unaffected shoulder dislocation and any other joint compensative dislocation following operation for atraumatic shoulder instability.
The first case was a 16 year-old woman. She sustained dislocation of the shoulder and was misdiagnosed as having recurrent dislocation of the shoulder by her previous doctor, and an arthroscopic shrinkage and two capsular shifts were performed for each shoulder. However recurrence developed, and she came to our hospital. Although glenoidplasty was performed for each shoulder, recurrence occurred. Therefore major pectoral muscle transfer was performed. No recurrent dislocation occurred. However, her fingers presented swan neck deformity. The second case was a 22 year-old woman. She dislocated her right shoulder habitually and glenoidplasty was performed. Recurrence developed one year later. Therefore arthroscopic thermal shrinkage was performed. Four months later, recurrence was seen and bilateral sternoclavicular joints and the left elbow were dislocated habitually. Her left shoulder changed to habitual dislocation. Recurrence of the shoulder dislocation of shoulders operated on for severe atraumatic shoulder instability presented more than a little, despite an exact diagnosis and surgery. We reported not only recurrence but dislocation of the unaffected shoulder or other joints. Sustained dislocation of the shoulder is a very rare dislocation. Keiser reported a woman who could not sustain the reduced position. Kuroda described two cases of sustained anterior subluxation of the shoulder. Though Keiser mentioned the possible implication of psychological factors, Kuroda said they were not indispensable. When doing surgery for atraumatic shoulder instability, you are required to pay attention to other joint dislocation secondarily.

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Extracorporeal Shock Wave Therapy for the Treatment of Nonunion of the Proximal Humerus Fracture and Humerus Shaft Fracture
-Report of 2 Cases-

Kaori SUGIOKA, Nobuyasu OCHIAI, Tomonori KENMOKU, Shinichi Sato, Takas ...

2011 Volume 35 Issue 3 Pages 1025-1028
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1025

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We performed extracorporeal shock wave therapy for two of cases nonunion due to humerus fracture and complete fracture healing was achieved in both cases. Case 1 was a 38-year-old man. He injured his right humerus in a traffic accident. Although open reduction and internal fixation with plate was performed and treated by low-intensity pulsed ultrasound two weeks after the operation, nonunion was found. Three sessions of extracorporeal shock wave therapy were performed from eight months after the operation. Sharp pain was reduced after the second treatment, an osteosclerosis was observed seven weeks later, and bone union was achieved in three months.
Case 2 was a 58-years-old woman who injured her right humerus in a traffic accident. Although she was operated on using ender pin, there was nonunion. Extracorporeal shock wave therapy was performed one year and four months after the operation and periosteum reaction was recognized after one month and bone union was achieved one year after the treatment.
The effectiveness of extracorporeal shock wave therapy for the treatment of nonunion cases was reported for the first time in 1991. In our cases, we performed extracorporeal shock wave for two nonunion cases of humerus, and bone union was achieved. Extracorporeal shock wave therapy is a less-invasive treatment, and it is thought to be better to try if before the decision of re-operation is made.

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A Case Report of Scapulothoracic Arthrodesis
for Congenital Clavicle Major Defect

Aya KANAZUKA, Nobuyasu OCHIAI, Tomonori KENMOKU, Kaori SUGIOKA, Takesh ...

2011 Volume 35 Issue 3 Pages 1029-1032
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1029

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We reported the scapulothoracic arthrodesis for congenital major defect of the clavicle. The Patient was an 18-year-old male. The chief complaints were asymmetric appearance and weakness of his right shoulder. Although most of the left clavicle had a congenital defect, there was no severe disability for activities of daily living, though he had a little limitation of range of motion in his left shoulder. He started to be concerned about the asymmetric appearance of his shoulder and he felt the weakness of his shoulder gradually with his growth. In this situation, we performed the scapulothoracic arthrodesis to treat the asymmetric appearance and to improve his shoulder function. The scapula was fixed on the second to sixth ribs using the reconstruction plate (SYNTHES) and Dole-miles cable. There were improvements not only the appearance but also the function of the shoulder after the surgery. He can maintain thr abducted position of his shoulder because of the improvement in the stability of the shoulder after scapulothoracic arthorodesis. Congenital major defect of the clavicle would be one of the indications for scapulothoracic arthorodesis.

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A Case of Positional Posterior Subluxation of the Stenoclavicular Joint, Treated by Ligamentous Reconstruction

Shintaro KOMAKI, Toru MORIHARA, Hisakazu TACHIIRI, Yosikazu KIDA, Tosh ...

2011 Volume 35 Issue 3 Pages 1033-1036
Published: 2011
Released on J-STAGE: December 21, 2011

DOIhttps://doi.org/10.11296/katakansetsu.35.1033

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We reported a case of positional posterior sublaxation of the stenoclavicular joint, treated by ligamentous repair. A twenty year-old male's chest was hit in the practice of Japanese martial art. He had left stenoclavicular joint pain and instability, he visited our hospital after seven months. When he flexed his left shoulder to 120 degrees horizontally, posterior displacement of the medial end of the clavicle was noted, and when he abducted his shoulder back to 0 degree horizontal flexion position, the joint was reduced. X-ray didn't reveal stenoclavicular dislocation, CT showed posterior sublaxation of the stenoclavicular joint. We diagnosed this as traumatic positional posterior sublaxation of the stenoclavicular joint, and performed an operation which was reconstruction of the costoclavicular ligament and the stenooclavicular ligament using a musculous tensor fasciae latae. Untill 8 weeks after the operation, he put on the clavicle band and trained ROM and low loading isometric exercise. At twelve weeks postoperatively, the patient returned to the sport. Dislocation of the stenoclavicular joint is estimated to have a prevealence of 1% in all dislocations, and posterior dislocation of the stenoclavicular joint is rare. We can find 187 reports of acute traumatic posterior dislocation of the stenoclavicular joint, but can't find any reports of the operative treatment of positional posterior subluxation of the stenoclavicular joint. In this case, we think that due to rupture of the ligaments and posterior articular capsule, sublaxation was habitual. For the purpose of reconstruction of the costoclavicular ligament and the stenooclavicular ligament, we did the Lowman's method and Speed's method. The operation lead to early return to athletic activity.

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