Background: In this study, shoulder joint position sense (SJPS) was studied in relation to tear size, patient's age and compared to the SJPS of the healthy side.
Methods: 115 of 182 shoulders that were repaired for cuff tear were studied. They were 75 male and 40 female, average age was 65.6 years. SJPS was assessed by active angle reproduction test. Each setting angle was measured 3 times, absolute value of the difference between the setting angle and the measured angle was studied. 73 uninvolved shoulders without pain and past history of shoulder disease and trauma were compared to involved side.
Results: In the relation between involved and uninvolved side, the error angles in the involved side were statistically higher than those of the uninvolved side at all setting angles. Statistical significances were not seen at each setting angle for the tear size. In a comparison of age, the error angle of 30 degrees of elevation in patient's whose age was 70 years or older indicated statistical larger degrees than those of under 70 years. (P=0.02). Statistical significance was not seen for other items.
Discussion and conclusion: SJPS of the rotator cuff tear is significantly lower than the opposite healthy side shoulder. The statistical difference of SJPS was not recognized with a difference of the age or a difference of the tear size.
Decreased SJPS in the rotator cuff tear, depended on the existence of the rotator cuff tear itself, and it was not affected by the tear size or age.

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Background: Shoulder injuries in baseball pitchers often occur at the maximum external rotation (MER). However, in the past, amounts and directions of the force applied to the shoulder at this moment during throwing motion has not been clarified. The purpose of this study was to analyze forces applied to the shoulder.
Methods: Biomechanical analysis was performed on 213 pitchers with various skill levels. Throwing motion was measured using motion capture system. To describe angular values of the upper arm relative to the trunk, Euler angle sequence was utilized. In order to estimate the resultant joint forces at the shoulder, an inverse dynamics technique was employed.
Results: The relationship between horizontal abduction/adduction angle and resultant anterior/posterior force at the MER showed significant correlation (r=-0.63, p < 0.05). The increase in horizontal abduction at this moment was associated with increased resultant anterior force. The horizontal adduction angle with minimal resultant anterior/posterior force at MER was 1.79°. Superior/inferior force at MER was poorly correlated with abduction/adduction angle, showing increased adduction angle associated with higher resultant force toward superior direction. Regarding the relationship between age and throwing kinematics, horizontal abduction angle at MER was larger in young pitchers than adult pitchers.
Conclusion: Comparison between horizontal abduction angle and anterior shear force at the MER in the throwing motion showed significant correlation. Evaluation and correction of the throwing motion focusing on horizontal abduction at MER may be a key to the reduction of harmful stresses leading to shoulder injuries among pitchers.

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Background: The purpose of this study was to determine the proper slice position for evaluation of muscle atrophy followed by rotator cuff tears.
Methods: Seventy-seven shoulders were arthroscopically evaluated for the presence and the size of the tear and included in this study. There were 14 shoulders with impingement syndrome (I), 14 small tears (S), 18 medium tears (M), 14 large tears (L), and 17 massive tears(MA). Data from preoperative MDCT after arthrography were analyzed by 3D image software. Oblique sagittal images were obtained and cross-sectional areas (CSAs) of supraspinatus (SSP), subscapularis (SSC), infrastupatus and teres minor (ISP+TM) were measured and muscle volumes were calculated.
Results: The position of the Y-shaped view was 16.8 mm medial from the glenoid surface. The volume of SSC and ISP+TM were not different, however, suprasupinatus muscle volume was significantly decreased in L and MA when compared to I. CSAs were maximal at 25 mm medial from the glenoid surface in SSP, 35mm in SCC, and 40mm in ISP+TM, respectively. The strongest correlation between muscle volume and CSAs was seen on 35 mm mediall to the glenoid surface in SSP, 40mm in SSC, and 55mm in ISP+TM.
Conclusion: Muscle atrophy occurred only in SSP when the size of the tear is larger than 30mm. The proper position for evaluating muscle atrophy is about 10 mm medial to the Y-shaped position for SSP. More medial slice is required for SSC and ISP+TM.

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Background: Capsular tear and the HAGL lesion are the important pathologies of the shoulder instability like Bankart lesion. The purpose of this study was to clarify the efficacy of the US in detecting capsular tear and HAGL lesion.
Methods: Subjects comprised 98 patients (mean age, 20.6 years, 78 men, 20 women) who underwent surgery for treatment of traumatic anterior shoulder instability. All shoulder joints were checked preoperatively by the US. The criteria of the capsular tear was the discontinuity or absence of the high echo line at the humeral head. The criteria of the HAGL lesion was the discontinuity or absence of the capsule at the humeral neck. Intraoperatively, we checked the anterior capsule and the attachment of the capsule at the humeral neck and made sure of the existence of capsular tear and HAGL lesion for all cases.
Results: Capsular tear was present in 30 cases and the HAGL lesion was present in 4 cases of 98 shoulder joints. Two cases where the size of HAGL lesion were 1 × 1cm were not able to be detected by US. In some cases that had a big capsular tear, we diagnosed them as HAGL lesion. The US had an accuracy of 89.7 % in the detection of a HAGL lesion and an accuracy of 85.6 % in the detection of a capsular tear.
Conclusion: We considered that the US is useful technique in detecting the capsular tear and the HAGL lesion.

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Background: Little Leaguer's shoulder is diagnosed mainly by radiography. The purpose of this study was to evaluate the usefulness of ultrasonography for diagnosis of Little Leaguer's shoulder compared with radiography.
Methods: 300 primary school baseball players underwent screening of throwing side elbow and shoulder in January, 2012. 24 subjects, who had tenderness to palpation over the proximal humerus, received ultrasonographic examination. The laterality of the width of proximal humeral epiphyseal line was measured. Sixteen of the 24 subjects received X-ray examination at outpatient clinic. The sensitivity, specificity and accuracy of ultrasonography for a Little Leaguer's shoulder was calculated using X-ray findings as a gold standard.
Results: The sensitivity, specificity and accuracy of ultrasonography for a Little Leaguer's shoulder were 87.5%, 87.5% and 87.5% respectively.
Discussion: Early diagnosis of shoulder and elbow disorders among young baseball players is important. Ultrasonography has been used for the diagnosis of elbow disorders at preparticipation physical examination (PPE). However, few reports are available on the use of ultrasonography for shoulder disorders at PPE. In our study, we attempted to detect a Little Leaguer's shoulder using portable ultrasonography and the sensitivity was 87.5%. Ultrasonography could be useful for the screening of a Little Leaguer's shoulder.

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Background: 3 dimensional ultrasonography (3DUS) of the supraspinatus(SSp) tendon and its operative findings were examined to evaluate the usefulness of 3DUS of the SSp tendon.
Methods: 19 patients complaining of shoulder pain were operated on after performing 3DUS on the involved shoulder. There were 14 males and 5 females, right side was involved in 11 shoulders, left in 8. The age at examination was 55.8 years old on the average (18-77). 3DUS of SSp tendon was made by rendering the images of 2DUSs. 3DUs were classified into 4 types by their sagittal shape; convex, irregular, flat and defect type. The SSp tendons were classified into 4 types by its appearance found at operation, no tear, partial tear, complete tear and massive tear (more than 3 tendons were involved.). The findings of 3DUS and operations were compared.
Results: 7 shoulders with convex type of 3DUS included not tear: 4, very small partial tear: 1 and complete tear: 2 (One was a longitudinal tear between SSp and ISp tendon). 7 shoulders with flat types included partial tear: 3, complete: 3 and massive:1. 5 shoulders with defect type revealed 4 tears and 1 massive tear. The SSp tendons with convex type accompanied no tear tendons compared with the other types(P=0.02 Kruskal-Wallis test). All the SSp tendons without convex type were verified as having some tendon tear.
Discussion: In spite of mechanical and technical difficulties, 3 DUS is a useful tool for detecting the cuff pathology, accompanied by 2DUS.

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Background: Evaluation of the glenoid for traumatic anterior shoulder instability is essential and imaging studies by scapula 3DCT and shoulder MRI have become standardized. However, carcinogenic risks by CT radiation have been reported and avoidance would be preferred. We evaluated the glenoid in bony Bankert lesion(BBL) by 3DMRI and compared this with the findings by 3DCT.
Methods: Six-teen cases that underwent both 3DCT and 3DMRI for traumatic anterior shoulder instability from January 2010 to May 2012 were included. An orthopaedic surgeon and a radiologist who were blinded to each other assessed the findings by 3DCT and 3DMRI, using 3DCT as the gold standard. Based on the results of 3DCT as the gold standard, the sensitivity and specificity of 3DMRI for detection of BBL were determined. Statistical significances of the size of bony fragment and the angle of bony defect between these two methods were calculated.
Results: Four cases were diagnosed as BBL by 3DCT and 3DMRI. The sensitivity of BBL by 3DMRI was 100% and the specificity was 83-100%. As to the quantification of the size of bony fragment and the angle of bony defect, 3DMRI(15.9 ± 4.8%, 87.5 ± 34.8°) and 3DCT(18.7 ± 5.4%,80.0 ± 29.4°) showed no statistical difference(p=0.144, p=0.109).
Conclusion: The sensitivity and specificity of BBL by 3DMRI were useful. 3DMRI is a reliable method for evaluating BBL and glenoid morphology. The result of a preceding 3DMRI could indicate the need for a further 3DCT. 3DCT of the shoulder could be omitted from pre-operative evaluation for anterior shoulder instability.

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Background: The objective of this study was to prospectively quantify the fatty degeneration of supraspinatus (SSP) muscle by using Dixon technique of MRI, and to evaluate the correlation with clinical findings including rotator cuff tears.
Methods: 258 patients with shoulder pain examined with 2-point Dixon technique of 3.0T-MRI were included in this study. Fatty degeneration was quantified after measurement of signal intensity value within the region of interest (ROI) placed over SSP muscle. Each signal intensity value of the image of in phase and fat image was defined as S(In) and S(Fat). The amount of fat contained in SSP was calculated as S(Fat)/S(In). Radiologists and orthopaedic surgeons evaluated the degree of rotator cuff tears in 3 categories: no tear, partial tear, complete tear. Statistical analysis was performed for correlation between the amount of fat in SSP and age, the degree of rotator cuff tears by using SSPS.
Results: The patients with full-thickness tear, partial-thickness tear and no tear are 47, 41 and 170 respectively. Correlation coefficient is 0.416 between age and fat amount in SSP. The degree of fat degeneration of SSP in the three groups showed statistically-significant difference (p< 0.001).
Conclusion: We can quantify and evaluate the degree of fatty degeneration within SSP by using Dixon technique of MRI objectively. Increased supraspinatus fatty infiltration was correlated with the age and severity of a supraspinatus tear.

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Background: Diffusion-weighted imaging (DWI) based on magnetic resonance imaging (MRI) can provide valuable information regarding the microstructure of tissues by monitoring the random movement of water molecules. The diffusion data can be used for determination of quantitative diffusion values such as the apparent diffusion coefficient (ADC). The purpose of this study was to evaluate rotator cuff muscle activity using DWI.
Methods: DWI was performed before and after loaded on empty can test and full can test and compared before and after those tests.
Results: ADC of supraspinatus, infraspinatus and superior portion of subscapularis were increased after empty can test. ADC of supraspinatus, superior portion of infraspinatus and superior portion of subscapularis were increased after full can test. Anatomical study showed that the infraspinatus had contributed in shoulder abduction in shoulder internal rotation.
Discussion: This study showed the agreement with the anatomy of the previous study, an increase of ADC in supraspinatus and infraspinatus in empty can test and an increase of ADC in supraspinatus mainly in full can test. There were possibilities that DWI could evaluate the activity of rotator cuff muscle.

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Background: Generally, MRI has been used for the evaluation of glenohumeral labrum. The purpose of this study was to evaluate the morphology of glenohumeral labrum and the injured regions of labrum by radial-sequence MRI.
Methods: 11 cases who had no injury of labrum who had arthroscopic surgery for rotator cuff tear and 17 cases who had anterior shoulder instability and underwent surgery with arthroscopic Bankart method were include in this study. In each case, the regions identified labrum shape was examined by radial and axial, coronal sections in MRI (fat suppression T2 weighted images). In cases that involved labrum injury, the injured regions identified by MRI were compared with arthroscopic findings.
Results: The regions identified labrum shapes were in almost all directions except 0:00-2:00 by radial-sequence imaging. The labrum shapes can be identified in wider regions by radial-sequence imaging than axial or coronal imaging. The regions of injured labrum in arthroscopy can be evaluated correctly in the 2:30-5:00 range by radial-sequence imaging.
Conclusion: The radial-sequence MRI methods was considered to be one of the useful methods for the evaluation of the shape of labrum and the region of labrum injury.

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Background: Shoulder 36 V.1.3 (Shoulder 36) aimed at objective and rational standards has been available since 2010. The preoperative evaluations of the patients who underwent arthroscopy were done using shoulder36 and Japan Orthopaedic Association Score (JOA score).
Methods: Forty-five shoulders of 44 patients who underwent arthroscopy were evaluated on the day before the operation. The mean age of the patients was 63.5 years old. The categories consisting of pain, range of motion (ROM), muscle strength, and activities of daily living (ADL) were evaluated.
Results: In both evaluations, excepting age, strong correlations were observed in ROM, ADL and muscle strength. However, no strong correlation was observed in pain between both evaluations.
Discussion: Pain, ROM and muscle strength have a great effect on ADL of the shoulder. Our study showed that shoulder 36 had a similar evaluation. Whereas for the JOA score, there is a possibility of being biased.

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Background: Recently the type of patient appraisal method used varies between fields. We investigated what kind of tendency is seen using The Japanese Orthopaedic Association Shoulder 36 V 1.3, and reported our results.
Methods: 110 shoulders in 85 patients who experienced shoulder pain were studied.
The method asked for The Japanese Orthopaedic Association Shoulder 36 V 1.3 at the time of the first medical examination, and collected them at the next medical examination. MRI and arthrography of the shoulder were carried out after all patients medical examinations, and classified the patients into three groups; shoulder periarthritis, rotator cuff tear and contracture of shoulder. The clinical recording, JOA score and The Japanese Orthopaedic Association Shoulder 36 V 1.3 were compared between the 3 groups.
Results: The contracture of shoulder group had the lowest JOA score and also the lowest in all six domains of The Japanese Orthopaedic Association Shoulder 36 V 1.3. Furthermore, in all domains the contracture of shoulder group was significantly lower than the other two groups (P < 0.001).
Conclusion: At the time of the first medical examination, the contracture of shoulder group had a tendency for restriction in everyday life to be stronger than the other two groups. We think that the functional disorder of contracture of shoulder can be evaluated by Shoulder 36 correctly.

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Background: Bankart's lesion is usually treated using suture anchors through an anterior portal. In some cases, it can be difficult to insert suture anchors at the inferior part of the glenoid via an anterior portal. In these situations or for management of humeral avulsion of the glenohumeral ligament lesion, a 5 o'clock portal needs to be made for inserting suture anchors.
Methods: Intra-operative ultrasound of the shoulder is introduced as a new method to establish the 5 o'clock portal for the treatment of traumatic anterior shoulder instability. The cephalic vein, the coracoid process and the conjoined tendon were marked using ultrasound before operation under general anesthesia in the lateral decubitus position. After standard arthroscopic release of anterior labrum or bony Bankart's lesion, the 5 o'clock portal was established using a slalom technique under ultrasound guidance in outside-in fashion. We inserted suture anchors and headless screws through this portal into the antero-inferior part of the glenoid.
Results: In four shoulders of four patients with a mean age of 26.0 years, arthroscopic Bankart or bony Bankart repair was performed. In all shoulders, we were able to establish the 5 o'clock portal using a slalom technique under ultrasound guidance in outside-in fashion. There were no complications.
Discussion: Because this portal is usually established using a blind slalom technique, some neurovascular structures, especially the cephalic vein and musculocutaneous nerve, can be at risk. We could visualize the route of cannula during placement of the portal and establish the portal safely and reliably under ultrasound guidance.

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Background: We reported a method for treating acromioclavicular(A-C) joint dislocation using two flip buttons and fiberwire in 2010. Now, we report about the problems of this method.
Methods: We referred to MINAR(Minimally Invasive AC joint Repair) reported by Wellmann et al, and made an original drill guide using bent elevatrium. A 4.5-mm drill was used to create a pilot hole in the base of the coracoid. A fiberwire loop was threaded through the internal eyelets of a flip button. Then, the prepared flip button was pushed through the coracoid drill hole and placed under the coracoid base. One end of the flip button was then passed through a 4.5-mm drill hole placed through the clavicle in line with the base of the coracoid. Afterward, repositioning the clavicle end, the fiberwire loop was tied. Operation time is about 50 minutes. Using this method, we performed A-C reconstruction on 4 cases (all male, average age 31.5y.o.)
Results: 2 cases had no pain, but there were sinking of flip buttons on the clavicles. Because 1 case suffered from deep infection, and cutting out of the flip button on the coraciod, we were forced to remove the flip buttons. We changed the size of flip button on the clavicle, and curve of the elevatrium.
Conclusion: We concluded that this method for A-C joint dislocation using two flip buttons and fiberwire has problems and measures.

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Background: Severe shoulder instability after initial dislocation may occur with disruption of the soft tissue and osseous restraints.
Methods: Four elderly female patients, who had a large deficit of the anteroinferior aspect of the glenoid with subluxation of the humeral head through a rent in the anterior capsulolabral complex, sustained an acute recurrence of instability. Arthroscopic capusulolabral and rotator cuff repair was performed using suture anchors.
Results: In all patients, stability was not restored following anchor fixation. Of the four patients, three had anteroinferior subluxation of the humeral head postoperatively. All of three patients had developed glenohumeral arthrosis and unsatisfactory functional scores at 1-year follow up.
Conclusion: Age at the time of initial dislocation, residual joint instability, and the intra-articular operative procedure to stabilize the glenohumeral joint potentially influenced the development of postoperative arthrosis.

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Background: While the initial treatment of anterior shoulder dislocation is closed reduction, the attempt at reduction may be unsuccessful in rare cases. We analyzed the patients who had been referred to our hospital as having “irreducible anterior dislocation of the shoulder” after the failure of attempted reduction.
Methods: Twenty-four patients with irreducible anterior shoulder dislocation were referred to us between 2005 and 2011. There were 2 men and 22 women, and the mean age at dislocation was 76.8 years old. We investigated their clinical and radiographic findings and the contents of our treatment.
Results: The primary dislocation was seen in 19 cases, and recurrent dislocation in 5 cases. Five cases had chronic dislocation in which more than 3 weeks had elapsed since dislocation. Imaging studies revealed 10 cases of dislocation and 14 cases of fracture-dislocation. Characteristically, deep and large Hill-Sachs lesion was engaged with anterior glenoid rim in 7 out of 10 dislocations, and greater tuberosity fractures were most commonly seen, 12 out of 14 fracture-dislocations. We attempted closed reduction again under anesthesia and fluoroscopic guidance in all but one case in which we immediately operated because of displaced anatomical neck and greater tuberosity fracture. As a result, closed reduction was successfully accomplished in 18 cases and failed in the remaining 5 cases. Surgery was undertaken in 4 out of the 5 cases.
Conclusion: Special caution should be paid to anterior shoulder (fracture-)dislocation occurring in elderly women because of its difficulty in closed reduction.

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Background: This study was conducted to verify the clinical results of arthroscopic posterior Bankart repair for traumatic posterior instability of the shoulder.
Methods: 11 patients (9 males and 2 females) who had arthroscopic posterior Bankart repair using suture anchors performed were included in this study. Their mean age was 19.4 years old and mean follow-up period was 13.3 months. A main symptom was pain on motion in 9 patients. Posterior shoulder subluxation at elevation was found in only 1 case. The range of motion (ROM) of the shoulder, JSS shoulder instability score (JSS-SIS) and clinical symptoms were investigated pre- and postoperatively.
Results: Detachment of posteroinferior labrum was found in all cases. Compared to preoperative condition, the postoperative ROM were slightly restricted in internal rotation at 90 degrees abduction. The JSS-SIS was improved from 66.4 points preoperatively to 93.4 points postoperatively. A slight apprehension in posterior load and shift test remained in 1 case. In 2 cases, return to sports or work was limited due to a pain. Recurrence was not found in all cases during follow-up.
Conclusion: There were few reports of clinical results after arthroscopic posterior Bankart repair. This study showed that arthroscopic posterior Bankart repair was useful for traumatic posterior instability of the shoulder.

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Background: Surgical treatment for acromioclavicular joint dislocations is recommended for Rockwood's classification type 4, 5, and 6. In this study, we evaluate the therapeutic results of modified Cadenat procedure on type 5 with acromioclavicular joint dislocation, and report on the comparative study of modified Dewar procedure on type 5 with acromioclavicular joint dislocation.
Materials and Methods: Modified Cadenat procedure was performed on 73 patients (66 males and 7 females; group C). The mean age at the time of the surgery was 35.4 years. Modified Dewar procedure was performed on 55 patients (51 males and 4 females; group D). The mean age at the time of the surgery was 34.5 years.
Results: The mean therapeutic results were 28.2 points in group C and 27.3 in group D according to UCLA scoring system. In group C, the subluxation that represented less than 5 mm superior translation of the clavicle, occurred only in 18 of 73 patients. Meanwhile, in group D, the subluxation that represented less than 5 mm, occurred only in 14 patients, that represented 5 to 10 mm in 7 patients, and the complete dislocation occurred in 3 patients. Also, the occurrence of osteoarthritic changes in acromioclavicular joint was nine patients in group C and 20 in group D.
Conclusion: Modified Cadenat procedure could provide satisfactory therapeutic results and avoid postoperative failure of reduction compared to modified Dewar procedure. However, modified Cadenat procedure does not aim to restore the anatomical coracoclavicular ligaments. We believe that anatomic restoration of both coracoclavicular ligaments could best restore the function of the acromioclavicular joint.

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Background: Many procedures have been described for treatment of complete acromioclavicular dislocations. However, the best primary treatment still remains unclear. The purpose of this study was to evaluate the clinical outcomes for patients with Rockwood type III /V acromioclavicular joint dislocation by modified Cadenat's procedure.
Methods: After reduction, the acromioclavicular joint was temporarily fixed using an acromiocavicular plate. Ligamentoplasty, using the corcoacromial ligament detached from the acromion process as a new ligament between the coracoid and the clavicle, was also performed. We retrospectively analyzed 25 consecutive patients (all men; mean age 43.9 years) according to the criteria of Japanese Orthopaedic Association score (JOA score) and the Japan Shoulder Society score for acromioclavicular dislocation score (JSS-ACj score). The acromioclavicular dislocation ratio and the coracoclavicular distance ratio were evaluated to assess AC separations radiographically.
Results: The postoperative JOA score and JSS-ACj score were 94.9 and 92.1, respectively. Acromioclavicular dislocation rates at injury, after the removal of the plate, and at follow-up were 151.5%, 11.5%, 34.4%, respectively. Coracoclavicular distances ratio at injury, after the removal of the plate, and at follow-up were 222.8%, 105.1%, 123.1%, respectively.
Discussion: Recently, an anatomical reconstruction of both the conoid and the trapezoid coracoclavicular ligament using of free tendon grafts has been described. However, the fractures associated with the clavicular bone tunnels were reported. The modified Cadenat's procedure is a simple procedure compared with an anatomical reconstruction, and could provide excellent results in both clinical and X-rays evaluation.

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Background: We reviewed the results of modified Cadenat procedure (C group), the surgery using Poly-L-lactic acid ligament augmentation device (PLLAD) (PL group), and non-operative treatment (N-O group) for grade III dislocation of the acromioclavicular joint.
Methods: There were 63 patients in C group, 10 in PL group, and 30 in N-O group. The average age was 35, 40, 35 years old respectively, and the average follow-up period was 27, 28, 11 months respectively. The surgery in PL group consisted of a primary suture of coracoclavicular ligaments augmented by PLLAD, which did not require a temporal fixation. The patients in N-O group were allowed to mobilize the shoulder 1 week after injury. The results were evaluated by Kawabe score in C and PL group, and JOA-AC score in N-O group. Osteolytic change of AC joint and calcification of CC ligaments were also evaluated on the X-ray.
Results: At final follow-ups, the average score was 93 points in C group, 92 points in PL group, and 94 points in N-O group. There were two patients who wanted the surgical treatment in N-O group because they had a shoulder pain during their sports activities. There was no difference of incidence of the calcification of CC ligaments. Though there was statistically less incidence of osteolytic change of AC joint in N-O group.
Conclusion: There was no statistical difference of the results between C and PL group. But non-operative treatment obtained almost the same satisfactory results.

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Background: Acromioclavicular joint separation is divided into three types according to Tossy and six types according to Rockwood. However, the trapezoid and conoid ligament that constitute the coracoclavicular ligaments are not detailed in these classifications. In this study, we investigated the location and degree of ligament injury in acromioclavicular joint separation by means of magnetic resonance (MR) images.
Methods: The study subjects were 25 patients (21 males, 4 females) and ranging in age from 19 to 58 years old (mean: 31.1 years old). According to Rockwood's classification criteria, these patients consisted of one case in type 1, seven cases in type 2, seven cases in type 3, and ten cases in type 5. All patients also had the procedure for MR images and enhanced MR images with intravenous gadolinium injection performed within 3 days after the occurrence of injury.
Results: Both the trapezoid and conoid ligaments had ruptured in five cases of type 3 and in ten cases of type 5. On the other hand, the conoid ligaments did not clearly demonstrate abnormal findings, but the trapezoid ligaments had ruptured in all cases of type 2 and in two cases of type 3.
Conclusion: The coracoclavicular ligaments injury evaluated by MR images and enhanced MR images were not always coincident with Rockwood's classification criteria from plain x-ray films, especially in type 2 and 3 of acromioclavicular joint separation.

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Background: The purpose of this study was to evaluate the operative outcome of acute acromioclavicular joint dislocation using Hook plate fixation with coracoclavicular (CC) ligament repair.
Methods: Nine male patients who underwent Hook plate fixation with CC ligament repair between January 2003 and April 2011 were evaluated. The mean age was 47 years old and the average follow-up period was 73.6 months. Preoperative dislocation after Rockwood's classification were Type III; 6 patients and Type V; 3 patients. The distance between the inferior margin of acromion and clavicle (AC distance) were measured on A-P view of plain X-ray before and after operation, after plate removal and at the final follow up. And the distance between the lateral edge of acromion and insertion of hook was measured.
Results: The mean active horizontal adduction: 140.0 degrees (135 - 155), abduction: 172.2 degrees (160 - 180), /Internal Rotation: T6 (T4 - T10). The average JSS score was 99.7 points (97 - 100). Results of the average AC distance before and after operation, after hardware removal and at the final follow up were as follows; 16.1mm (10 - 26), 0.7 mm (0 - 3), 1.4 mm (0 - 4), 1.4 mm (0 - 3) respectively. The average distance between the lateral edge of acromion and insertion of hook was 16.1 mm (11 - 22). Six patients (66.7%) had loosening of plate hook and subacromial erosion at one to two months after operation.
Conclusion: Hook plate fixation with CC ligament repair yielded functionally and radiologically successful outcomes.

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Background: We evaluated the postoperative outcomes of arthroscopic Bankart repair for Self Defense Forces personnel with traumatic shoulder instability.
Methods: From 2003 to 2012, 91 patients (97 shoulders) underwent arthroscopic Bankart repair in our hospital and 59 patients (63 shoulders) were available for this study either by examination or telephone survey. The mean age at the surgery was 25.6 years (18 to 42 years) and the mean duration of follow-up was 42.1 months (12 to 105 months). Clinical outcomes were evaluated on the JSS Shoulder Instability Score (SIS), JSS Shoulder Sport Score (SSS), JOA score, Rowe scale, UCLA scale and DASH score.
Results: Fifty five cases (93%) recovered to the preoperative military trainings. Postoperative re-dislocation occurred in 2 shoulders (3.2%). The mean JSS-SIS was increased from 59.1 points to 88.7 points, the mean JSS-SSS was increased from 58.0 points to 83.3 points, the mean JOA score was increased from 74.7 points to 96.2 points, the mean Rowe scale was increased from 48.9 points to 96.3 points, the mean UCLA scale was increased from 19.3 points to 28.3 points, the mean DASH score was improved from 11.0 points to 3.2 points. All of these scores showed significant improvement (p < 0.01).
Conclusion: A Self Defense Forces usually demanded highly activity from personnel, especially in the young, so open Bankart & Bristow procedure was recommended for these patients with traumatic shoulder instability. However, arthroscopic Bankart repair showed satisfactory results as well as open Bankart & Bristow procedure.

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Background: The purpose of this study was to compare the clinical results of modified open Bankart & Bristow procedure with union of the transferred coracoid process (BB union group), with nonunion (BB nonunion group) and open Bankart repair (OB group) for traumatic anterior shoulder instability of collision and contact athletes.
Methods: We studied 48 shoulders in BB union group, 17 shoulders in BB nonunion group and 18 shoulders in OB group retrospectively. We evaluated the clinical outcome using recurrence rate, return to sports activities, the JSS Shoulder Instability Score (JSS-SIS) and Rowe score.
Results: As for recurrence after surgeries, no cases (0%) in BB union group, one case (5.9%) in BB nonunion group and 4 cases (22.2%) in OB group were experienced. Forty three cases (95.6%) in BB union group, 15 cases (88.2%) in BB nonunion group and 12 cases (66.7%) in OB group completely returned to their preoperative sports activities on average at 4.5, 4.7 and 7.4 months respectively. The JSS-SIS and Rowe score were 95.4 and 96.0 points in BB union group, 91.9 and 92.3 points in BB nonunion group and 82.5 and 76.7 points in OB group at the time of final investigation. The BB nonunion group showed similar results to BB union group these good results were different from OB group results.
Conclusion: It is assumed that stabilizing mechanism of the shoulder for open Bankart & Bristow procedure is not only due to bone block of transferred coracoid process in front of the glenoid neck but also mainly the adhesion of transferred conjoined tendon to subscapularis muscle and the dynamic buttress effect by transferred conjoined tendon across the antero-inferior aspects of the glenohumeral joint.

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Background: The purpose of this study was to present the technique and to examine the short term results of arthroscopic Bankart-Bristow modified procedure, in high-demand collision and contact athletes with traumatic anterior shoulder instability.
Methods: Fourteen collision and contact athletes ranging from 15 to 21 years of age (average, 19.5 years) were studied. The mean follow-up was 11 months (range 6-16 months) after surgery. Five portals (posterior, anterior, anterolateral, anterosuperior : coracoid portal, inferomedial : Pectoralis Major portal ) were used. The osteotomized coracoid fragment inserted with a cannulated cancellous screw was passed with the conjoined tendon through the subscapularis muscle, and fixed in the standing position on the abraded glenoid neck. The capsule and labrum were then reattached on the glenoid rim using 2 to 4 absorbable suture anchors. The rate of return to preoperative sports activities and the rate of recurrence after surgery were evaluated. The clinical outcome measures included the JSS Shoulder Instability Score (JSS-SIS) and Rowe score.
Results: All of the cases (100%) returned to their preoperative sports from 3 to 5 months after surgery (average 4.1 months). No cases experienced re-dislocation. At the time of the last investigation, the average JSS-SIS and Rowe scores were 96.6 and 95 respectively.
Conclusion: In this study, arthroscopic Bankart-Bristow modified procedure allow an early return to the preoperative collision sports in high-demand collision and contact athletes with traumatic anterior shoulder instability.

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Background: Since 2011, our department has conducted arthroscopic Bristow & Bankart method, depending on the case focusing on contact sports players. We report the operative method of the arthroscopic Bankart Bristow method and its short-term results.
Methods: We reported results in 12 cases of Bankart Bristow method that were available for follow-up more than six months after surgery. The examination items used were JSS score and ROWE score preoperatively and six months after surgery.
Results: In JSS score, the preoperative score was ave 45.1 and the Postoperative was 72.8. In ROWE score, the preoperative score was 19.7 and the postoperative was 78.2. Solid bone union was obtained in ten cases within three months, but there were two cases which remained in a fibrous union state four months after of operation.
Conclusion: This operative method was thought to be able to deliver clinical outcome without the inferiority compared with Modified open Bristow procedure.

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Background: Arthroscopic osseous Bankart repair was introduced almost a decade ago and, not a few surgeons recognized the effectiveness of this procedure especially for shoulders with significant bone loss. However, due to the lack of reported mid to long term outcome, many surgeons are still skeptical about the benefits of this surgery. Therefore, this study was designed in order to assess long term outcome and glenoid morphologic change using 3DCT after the index surgery in a retrospective fashion.
Methods: Eighty-five patients with recurrent anterior glenohumeral instability associated with osseous Bankart lesion underwent arthroscopic osseous Bankart repair from January 2005 through December 2006. Glenoid bone loss was measured as a percentage loss of the glenoid width against the diameter of the assumed inferior circle regardless of fragment size using en face view of 3DCT. Forty-six patients with more than 15% glenoid bone loss were selected as candidates for this retrospective study. However, 16 patients were lost to follow-up, therefore, subjects consisted of 30 patients (follow-up rate 65%), including 27 males and 3 females with an average age at the time of surgery of 24.1 years. During the final follow-up, each patient underwent clinical and 3DCT examinations. Clinical outcome was assessed using Rowe scoring system and Western Ontario Shoulder Instability (WOSI) Index. Glenoid bone loss was measured and compared with the preoperative bone loss. Statistical analysis was performed using the paired t-test. The significance level was set at p = 0.05.
Results: Although one patient suffered redislocation 6 months after surgery before obtaining bony union, none of the others experienced any events related to shoulder instability. The mean postoperative Rowe score and WOSI significantly improved from 31.2 to 97.9 and from 1508 points to 132 points, respectively. The mean postoperative glenoid bone loss was improved from preoperative 21.0%(15.1% -- 29.7%) to -0.9%(-10.9% -- 6.3%) (p < 0.0001), and glenoid morphology was normalized in all patients postoperatively.
Conclusion: Arthroscopic osseous Bankart repair for shoulders with significant glenoid bone loss can expect a successful outcome without recurrence once bony union is obtained. Glenoid morphology can be almost normalized during the mid to long term postoperative period.

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Background: Recurrent shoulder dislocation usually occurs in youth, but is not rare in middle -aged and elderly individuals. We report short-term clinical outcomes of arthroscopic surgery for treating recurrent anterior shoulder dislocations in middle-aged and elderly individuals.
Methods: The study included 7 patients (4 men and 3 women). Their age at the time of surgery was 46 to 83 years (mean age, 63.4 years). The follow-up period ranged from 7 to 24 months (mean follow-up, 18.6).
Results: All patients had Bankart lesion and rotator cuff tear. We performed arthroscopic repair for the Bankart lesion and torn cuff. Postoperative clinical outcomes were evaluated by determining the Japanese Orthopaedic Association (JOA) and the Japanese Shoulder Society Shoulder Instability (JSS-SI) scores. No patient developed recurrent anterior shoulder dislocation after the surgery. Mean JOA score improved from a preoperative score of 52.3(30 to 67) points to a postoperative score of 91.1(76 to 100) points. Moreover, mean JSS-SI score improved from 32.4(5 to 52) points before the surgery to 84.6(75 to 92) points after the surgery.
Conclusion: Arthroscopic procedure is a less invasive technique to repair Bankart lesion and torn cuff and is suitable for elderly patients who have less muscular strength and develop joint contracture easily.

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Background: Humeral avulsion of glenohumeral ligaments (HAGL) is an increasingly recognized cause of recurrent shoulder instability. However, the pathology and treatment outcomes in this rare injury are still unknown. The purpose of this study is to report the clinical characteristics and treatment outcomes in patients with a HAGL lesion.
Methods: Fifteen cases of HAGL lesion that underwent an arthroscopic stabilization for recurrent anterior glenohumeral instability between 2005 and 2010 were reviewed retrospectively. There were 10 males and 5 females with an average age of 27 years old. Causes of first time injury and sports activities were assessed using medical records. Preoperative 3DCT, MR arthrography and the details of surgery were reviewed.
Results: The incidence of the HAGL lesion was 2.4%. Most of the patients were participating in high activity sports including snowboarding, rugby and combative sports, when injured. Preoperative 3DCT revealed a bony Bankart lesion in 2 cases, mild erosion in 9 cases and 4 normal glenoid. MR arthrography showed the disruption of the inferior capsule or J-shape axillar pouch on the oblique coronal image in all cases. All lesions were repaired arthroscopically with 1.3 suture anchors and 0.86 stiches on average. A competitive rugby player's shoulder was dislocated after surgery. The recurrence rate was 6.7%.
Conclusion: HAGL lesion was frequently observed in patients participating in high energy sports. The glenoid morphology was relatively well preserved and the oblique coronal image in MR arthrography was a feasible assessment preoperatively. Arthroscopic stabilization of the HAGL lesion yielded satisfactory outcomes.

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Background: Rehabilitation for shoulder surgery is important. However it is often difficult for patients to receive adequate ambulatory rehabilitation, therefore self home exercise is a major way of rehabilitation. The purpose of this study is to research the effect of home exercise on postoperative results of arthroscopic Bankart repair(ABR).
Methods: 19 cases underwent ABR and were followed-up for more than one year. A questionnaire was made as to the frequency and duration of postoperative home exercise. Factors related to recovery in JSS shoulder instability score from postoperation to 1year and the increase in JSS SIS postoperation 6 months to 1year were analyzed. Statistical official approval set 5% as a level of significance using regression analysis.
Results: Recovery in JSS shoulder instability score is 13.8 ∼ 122％(average58.6). It was related to the duration of home exercise until 3 weeks (p=0.04)and total time of exercise from 6 to 9 months post operation(p=0.03), and the duration of home exercise from 9 months to 1 year(p=0.03) .The increase of JSS-SIS after 6months was --21.3 ∼ 51.9％(average 27.6）and was related to the duration of home exercise from 6 to 9 months(p=0.02) and age(p=0.03).
Discussion: Home exercise from 6months upward affects the outcome of ABR. It suggests that we should encourage patients to do home exercise especially after 6months.

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Background: The purpose of this study was to evaluate the long-term results of Latarjet procedure and determine the prevalence and risk factors of glenohumeral arthritis.
Methods: Three hundred and thirty-four Latarjet procedures were performed between 1988 and 1993 for the treatment of anterior glenohumeral instability. A retrospective review was available for 68 shoulders. The mean age at the time of surgery was 29.4 years. The mean follow-up period was 20 years. All patients had a clinical and radiographic evaluation preoperatively and postoperatively. Clinical results were evaluated with Rowe score, Subjective Shoulder Value (SSV) and recurrence. Radiographic sign of arthritis was evaluated with the classification of Samilson-Prieto.
Results: At final follow-up, the mean Rowe score increased from 37.9 to 89.6. The mean SSV was 90.9%. Postoperative recurrence occurred in 4 of 68 shoulders, with dislocation in 2 shoulders and subluxation in 2 shoulders. The preoperative incidence of arthritis was 11.8% (8 shoulders, all Stage 1). Postoperative arthritis in patients without any preoperative arthritis occurred in 12 shoulders (17.6%) and progression of preoperative arthritis occurred in 4 shoulders (5.9%), which was stage 1 in 6 shoulders, stage 2 in 4, stage 3 in 6 and no stage 4. Arthritic risk factors were old age at final follow-up, high demand sports activity after surgery and lateral overhang of coracoid bone graft.
Conclusion: Latarjet procedure for anterior glenohumeral instability provides excellent long-term results. The prevalence of postoperative development of arthritis is 20% at 20 years follow-up, but no severe arthritis like stage 4.

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Background: The purpose of this study is to determine a factor influencing the injury form of the Bankart lesion and the Hill-Sachs lesion in traumatic anterior instability cases.
Methods: 110 shoulders with traumatic anterior instability were included in this study. There were 83 men and 27 women, and the mean age was 25.3 years old (range 14 to 61 years). We evaluated their Bankart lesions and Hill-Sachs lesions using CT arthrography and classified them in the following two groups by injury form. For Bankart lesion, group B1 included 61 shoulders with only labrum lesion, group B2 included 49 shoulders with bony lesion. For Hill-Sachs lesion, group H1 included 49 shoulders with narrow cartilage lesion, group H2 included 61 shoulders with wide cartilage lesion. We investigated age, gender, dislocation form (dislocation / subluxation), dislocation frequency, general joint laxity (Beigton score), the presence of the rotator cuff insufficiency tear and unaffected side shoulder range of motion (ROM) between the two groups each.
Results: For the Bankart lesion, group B2 had significantly higher age, and ROM of each direction of flexion, abduction, external rotation and the horizontal extension was significantly smaller than group B1. For the Hill-Sachs lesion, group H2 had significantly higher age, and a significantly higher rate of cases of dislocation than group H1.
Discussion: This results suggests the possibility that the Bankart lesion and the Hill-Sachs lesion became severer as the elderly patients at initial dislocation.

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Background: In our hospital, the air-contrast computed tomography arthrography (CTA) is one of the preoperative examinations for patients with recurrent dislocation of the shoulder. Although the potency of CTA has improved by multidetector CT, there is some difficulty in detecting the antero-inferior glenoid labral lesions clearly. In this study, we examined features of the patients with antero-inferior glenoid labral lesions which were difficult to detect by the air-contrast CTA.
Methods: We performed air-contrast CTA in 29 patients who had no osseous fragment of glenoid and underwent arthroscopic Bankart repair between 2007.1 and 2012.5. The frequency of dislocation/subluxation, duration from the primary dislocation to arthrography, the bone-deficit size of the glenoid and the rotational position of the humeral head in CT image were evaluated in these patients.
Results: Antero-inferior glenoid labral lesions were undetectable in three patients by the air-contrast CTA and two of three were Perthes lesions. In these patients, the mean frequency of dislocation was lower than that of all other patients, and the mean duration from primary dislocation was 12.7 years. Mean bone-deficit size of glenoid was 2.9% that is smaller than that of all other patients (9.5%). The rotation of humeral head tended to be more external compared with the overall mean and we speculated that the subscapularis muscle holds the articular capsule down by external rotation.
Conclusion: Features of the patients with undetectable antero-inferior glenoid labral lesions by the air-contrast CTA were a lower frequency of dislocation, smaller bone-deficit of glenoid and more external rotation of the humeral head.

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Background: The difference between subluxations and dislocations of the long head of the biceps tendon (LHB) combined with the complete rotator cuff (RC) tear was examined.
Methods: There were 7 shoulders with dislocation and 5 with subluxation, which had open cuff surgery. The clinical observations, image findings, and condition of LHB and RC were evaluated.
Results: Major trauma at onset was found in 3 shoulders with dislocation and 2 with subluxation. Biceps muscle deformity was not found, and the active shoulder elevation angles were an average of 74 degrees. There were no significant differences in these factors between dislocations and subluxations. XP revealed ascent of the humeral head in 5 shoulders with dislocation. MRI revealed medial displacement of LHB from the biceps groove in all cases. All 7 dislocations had supraspinatus, infraspinatus and subscapularis tendon tears, and 5 subluxations had supraspinatus tendon tears in all, infraspinatus tendon tears in 2 and upper half of subscapularis tendon tears in all. The tear size in dislocations was significantly larger than that in subluxations. The flattening of LHB was present in 9 shoulders. The remaining 3 shoulders, without the flattening, had major trauma at onset. All RC tears were repaired by using tenodesis of LHB at the superior facet.
Conclusion: The progress of displacement of LHB was thought to be related to the expansion of RC tear. When there is no biceps muscle deformity and no LHB in the biceps groove at surgery, it is necessary to suspect subluxation and dislocation of LHB.

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Background: We experienced 2 cases of axillary artery injuries complicating proximal humeral fracture. Preoperative CT images were evaluated retrospectively in patients with proximal humeral fractures who underwent surgery in our hospital. The purpose of this study is to evaluate the association between the medial displacement of the humeral shaft and axillary artery injuries.
Methods: A total of 27 patients with proximal humeral fractures who underwent open reduction and internal fixation between April 2010 and March 2012 were included in this study. There were 11 men and 16 women with a mean age of 63.0 years (24 to 92 years). We retrospectively evaluated preoperative CT images, and the distance between the medially displaced humeral shaft and the axillary artery was assessed.
Results: Axillary artery injury was observed in 2 patients. The distance between the medially displaced shaft and the axillary artery showed a significant difference between the group with axillary artery injury (injury group: Group I) and the group without axillary artery injury (non-injury group: Group NI).
Discussion: We consider that there is a risk of axillary artery injuries at the time of injury or reduction when patients have remarkable medial displacement of the shaft in a proximal humeral fracture, regardless of the AO classification, and therefore require adequate attention. We suggest that patients with remarkable medial displacement of the shaft in a proximal humeral fracture undergo preoperative CT angiography or doppler ultrasound to evaluate the risk of axillary artery injury.

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Background: Proximal humeral fracture in aged individuals occurs frequently as a complication of a fall. There are few reports on the functional prognosis based on a patient's subjective point of view. There is a concern of high frequency of subsequent falls and resultant fractures, and if the locomotive organs are not properly managed. The purpose of this study was to investigate the patient's subjective shoulder function, the risk and frequency of subsequent falls in elderly patients after proximal humeral fracture.
Methods: The enrollment criteria were; patient aged over 65 years, diagnosed as having a proximal humeral fracture, and being followed up for more than 12 months. A questionnaire was sent to the patients to investigate the shoulder function by Shoulder36V1.3 and the risk of subsequent falls by the 5-question Geriatric Locomotive Function Scale (GLFS-5).
Results: Forty-two patients (4 male, 38 female, mean age 76 y.o.) satisfied the criteria and 22 patients (3 male, 19 female, mean age 76 y.o.)(62%)replied to the questionnaire. Among them, Shoulder 36 were lower compared to the age-matched control group. The mean GLFS-5 scale was 9.8 points and 16 patients (73%) met the criteria of locomotive syndrome. Six patients (27%) had actually experienced the subsequent falls.
Discussion: This study found unsatisfactory subjective shoulder function and high prevalence of locomotive syndrome in elderly patients after proximal humeral fracture. A new management system should be established, that includes not only to improving shoulder function but also managing locomotive syndrome, to prevent the subsequent falls in the elderly population.

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Background: The purpose of this study is to compare Delto-pectral approach with Deltoid-splitting approach and to examine the merits and demerits of Deltoid-splitting approach.
Methods: The subjects were 11 patients who had proximal humerus fractures and who were treated with PHILOS^TM in our hospital.
Results: All the cases showed bone union. There was no development of symptoms of axillary nerve palsy.
Discussion: Delto-pectral approach, which is a conventional surgical approach for open reduction internal fixation (ORIF) for proximal humerus fracture, is skin incision that advances from the front of the shoulder joint. The optimum installation position of a plate in the proximal humerus fracture is outside. Because the deltoid-splitting approach of the present study is a surgical approach from the outside, the plate can be easily placed to the optimum installation position as compared with the conventional approach. Even in cases with dislocation in the greater tuberosity, bone fragments can be easily reduced and held. A risk of axillary nerve palsy, which appears to be a demerit of this approach, the nerve is palpable with fingers from behind the deltoid; therefore, we consider that it is completely preventable by inserting the plate along the periosteum.

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Hypothesis: The Rope-over-bitt method is effective for varus deformities using Polarus Humeral Nail in Proximal humeral fractures.
Methods: Between September 2004 and December 2011, 56 shoulders of 56 patients (45 females, 11 males) underwent intramedullary fixation using the Polarus humeral nail and 25 shoulders used Rope-over-bitt method. According to the Neer classification, 37 fractures were classified into surgical neck 2 part types, 14 were greater tuberosity 3-part types, 1 was lesser tuberosity 3-part type, 2 were 4-part types, 2 were fracture dislocation types, and 1 was unclassifiable. We checked radiographic results, JOA scores, the range of shoulder motion, and the changes between the post operative neck-shaft angle and that of the last follow up, and investigated the differences between the cases with Rope-over-bitt method (group A) and those not using it (group B).
Results: All cases obtained bone union. The mean active flexion was 142°, ER 46°, IR L1 and average JOA score was 83.3 points. The average changes of neck-shaft angle was 5.4°. Over 20° changes of neck- shaft angle were seen in only group B and all cases were classified into the greater tuberosity 2-part fractures.
Conclusion: Rope-bitt method in intramedullary fixation is effective to prevent the post operative varus deformity.

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Background: Proximal humeral fracture in aged individuals occurs frequently as a complication of osteoporosis. If the osteoporosis, or primary disease, is not properly managed, there is a concern of high frequency of subsequent osteoporotic fractures. Our objective was to investigate the risk of subsequent fractures and the rate of osteoporosis treatment in elderly patients after proximal humeral fracture.
Methods: The enrollment criteria were; patient aged over 65 years old, diagnosed as having proximal humeral fracture, and followed up for more than 12 months. The data of each patient was extracted from their medical record to evaluate the 10-year probability of fracture risk using FRAX. A questionnaire was sent to the patients to identify the rate of subsequent fractures as well as the osteoporosis treatment.
Results: Forty-two patients (4 men, 38 women, mean 76 years old.) satisfied the criteria. The risk of subsequent osteoporotic fracture in this group was 26% on average. Twenty-three patients replied to the questionnaire. Among them, three patients (13%) suffered subsequent fractures. Only 5 patients (23%) underwent osteoporosis treatment.
Discussion: This study cautioned that there was a high risk of subsequent fractures but little treatment of osteoporosis was carried out in elderly patients after proximal humeral fracture. A new patient management system that includes systemic treatment of osteoporosis should be established to prevent the subsequent fractures, especially in the elderly population.

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Background: The purpose of this study is to evaluate the clinical results of surgical treatment for proximal humeral fractures in patients over 75 years old.
Methods: 47 elderly patients who were over 75 years-old were followed for more than 6 months after 2007. Open reduction and internal fixation (ORIF group), in which patients were treated with locking compression plate (LCP group) or interlocking nail (N group), consisted of 19 shoulders (1 man, 18 women) in LCP group and 20 shoulders (4 men, 16 women) in N group, and there were 8 shoulders (8 women) in humeral head replacement (HHR group). All patients were evaluated with Neer classification, JOA score, range of motion of flexion and external rotation. Mann-Whitney's U test was used for Statistical analysis.
Results: Postoperative flexion angle was 111.6 degrees in LP group, 110.8 degrees in N group, and 66.9 degrees in HHR group. Postoperative external rotation angle was 32.1 degrees in LP group, 30.8 degrees in N group, and 6.3 degrees in HHR group.
Discussion and conclusion: The clinical results of surgical treatment for proximal humeral fractures in patients over 75 years old were not better than that of previous reports in younger patients. ORIF group has better clinical results rather than HHR group. ORIF is desirable if possible, however, when ORIF is impossible because of comminuted fracture or osteoporosis, HHR must be chosen. Furthermore, in elderly patients, complications and dementia lead to difficulty of rehabilitation.

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Background: We had used needle wires to fix greater and lesser tuberosity fragments and humeral prosthesis. The purpose of this report was to evaluate the cable wire system for shoulder hemiarthroplasty.
Materials and Methods: We performed hemiarthroplasty on 32 patients. Six cases were male and 26 were females. The average age was 73 years. The mean follow up period was 4.6 years. We evaluated the results by the Japan Orthopeadic Association`s (JOA) score.
Results: The average postoperative JOA score was 85.1. The average angle of the active flexion was 126 degrees.
Conclusion: The cable wire system was considered to be effective to fix greater and lesser tuberosity.

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Background: The incidence of 3- or 4-part fracture of the proximal humerus in elderly people has been increasing according to some recent reports. Thus careful attention should be paid to the treatment of unstable humerus proximal fracture in eldery. In this study, we show our clinical consequences of hemiarthroplasty for the treatment of proximal displaced, unstable humerus fractures.
Methods: Eleven patients including 1 male and 10 females (11 shoulders) underwent hemiarthroplasty due to having 3- or 4-part fracture of the proximal humerus. The mean age at the surgery was 74.9 years (66 to 90 years) and the mean follow-up period was 20.9 months (6 to 86 months). We evaluated Japanese Orthopedic Association (JOA) Shoulder Score in addition to the range of motion (ROM) and radiographic findings including acromiohumeral interval (AHI) and displacement of greater tuberosity.
Results: The mean active ROM was 90 ± 26° in flexion, 81.8 ± 31.2° in abduction and 24.4 ± 32.2° in external rotation. JOA score at the final clinical checkup was 72.8 ± 11 points (Pain: 24.1 ± 5.8, Function:14.7 ± 3.5, ROM: 18.5 ± 5.5, X-ray: 3.73 ± 1.0, Stability: 11.8 ± 2.5) on average. In radiographic findings, 8 shoulders indicated excessive displacement of greater tuberosity (more than 10mm) and 4 shoulders showed less than 5 mm in AHI.
Conclusion: Our study suggested that hemiarthroplasty for a proximal humerus fracture in the elderly resulted in good pain relief, however, it might be less effective in terms of the functional and ROM recovery.

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Background: Recently there have been good clinical results for proximal humeral fractures treated with the locking plate. The purpose of this study was to evaluate the clinical outcome of locking plate osteosynthesis for proximal humeral fractures.
Methods: The patients were followed-up for more than 6 months postoperatively. We evaluated 21 cases (5 males and 15 females) treated with a proximal humeral internal locking system (PHILOS). The average age at operation was 70 years old (46 ∼ 87 years old). The mean follow up period was 12.4 months (6 ∼ 25 months). We investigated JOA score, range of elevation, neck/shaft (N/S) angle and complications.
Results: The average JOA total score was 83 (52 ∼ 100) points and the average range of elevation was 124.8°(50 ∼160°). The average N/S angle was 139.0°(123 ∼ 198°: post operation) and 138.3°(114 ∼ 198°: final follow up). There was 1 case of osteonecrosis, 1 case of upward transposition of the greater tubercle, 1 case of varus displacement, and 4 cases of screw penetration of screw.
Conclusion: The clinical outcome was mostly satisfactory. PHILOS is useful because it provides angular stability. But some complications exist such as osteonecrosis, upward transposition of the greater tubercle and varus displacement. It is necessary to treat osteoporotic bone more carefully, with good reduction and fixation.

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Background: The purpose of this study was to investigate the outcome of surgical treatment for proximal humerus fractures using Multiaxial Fixator Plates (MF-P).
Methods: The study sample involved 9 patients (3 male and 6 female). Their average age at surgery was 67 years old, ranging from 48 to 86. According to Neer classification, there were 3 patients with a 2-part fracture and 6 with a 3-part fracture. The average follow-up period was 2 years and 9 months. The ratio of bone union or avascular necrosis, back-out or perforation of the screw, and varus displacement of the humeral head, the range of motion (ROM) of the shoulder joint, and the Japanese Orthopaedic Association (JOA) score after surgery were evaluated.
Results: All patients, who were followed for more than 6 months post-surgery, had bone union within 4 months. Avascular necrosis was not found in any patients after surgery. ROM at final follow-up averaged 123 degrees elevation and 49 degrees external rotation. None of the patients developed impingement by the plate. Perforation of the lag-screw occurred in one patient. Screw back-out was seen in 2 patients, which resulted in varus displacement of the humeral head. The average JOA score was 86 points post-operatively.
Conclusion: The results of surgical treatment for proximal humerus fractures using MF-P were satisfactory. However, care must be taken after surgery for patients who have severe osteoporosis and low compliance because these patients have a higher risk of displacement soon after surgery.

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Background: The purpose of this study was to evaluate the clinical results of suture anchor fixation of displaced greater tuberosity fractures of the humerus.
Methods: Between 2005 and 2012, a total of eight patients (3 males and 5 females) with displaced greater tuberosity fractures of the humerus had suture anchor fixation. The mean age was 69 years old (range, 62 to 85). The duration from injury to surgery was 74.4 days (range, 7 to 245). The average duration of follow-up was 25.5 (5 - 60) months. We evaluated the medial and superior distance from the humeral heads to the displaced bone fragment, the range of motion (flexion, abduction, external rotation (ER)) and JOA score.
Results: The preoperative distance of superior and medial displacement was 19.6mm (range, -5.9 to 43.0mm) and 8.4mm (range, 1.3 to 16.7mm) respectively. At final follow-up, mean flexion was 91.9 (range, 60 to 140°), mean abduction was 86.3°(range, 50 to 140°), ER was 21.9°(range, -20 to 60°) and mean postoperative JOA score was 72.9 (range, 63 to 87).
Conclusion: The larger the displacement and the longer the interval from injury to surgery, the more likely that there will be a worse clinical result. We therefore conclude that suture anchor fixation is a useful procedure in the treatment of displaced greater tuberosity fractures of the humerus.

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Background: Although open reduction and internal fixation is frequently recommended for displaced greater tuberosity fractures of the humerus associated with shoulder dislocations, only sparse follow-up data have been reported. The purpose of this retrospective study is to determine the results of surgical treatment of displaced fractures of the greater tuberosity associated with dislocation of the shoulder joint.
Methods: Between April 2006 and October 2011, we treated eight patients by open reduction and internal fixation. Their mean age was 73.0 years (range, 58 to 90 years). The indication for the operation was one centimeter or more displacement of greater tuberosity after glenohumeral reduction. At the time of operation, the greater tuberosity fragment was repaired into its bed with multiple sutures and suture anchors. At the follow-up, we evaluated the range of motion of shoulders and JOA shoulder scores. Radiographs were assessed to determine union of the greater tuberosity.
Results: Seven of the eight fractures healed without loss of reduction. One fracture had redisplacement after surgery. At the follow-up evaluation, the mean active elevation of the shoulders was 119.4 degrees (range, 40 to 160 degrees), mean external rotation was 32.5 degrees, (range, 20 to 60 degrees). Mean JOA score was 86.1 points (range, 66 to 97 points). One patient who had redisplacement of the fracture showed a poor clinical outcome at the final follow-up.
Conclusion: In greater tuberosity fractures associated with dislocation of the shoulder joint, good clinical results would be expected by open reduction and internal fixation.

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Background: Scorpion Plate ^® is an instrument specializing in fixation for distal clavicle fracture, featuring systems which do not cross acromio-clavicular joint and hooks to grab the distal fragment. The purpose of this study was to evaluate the postoperative results of distal clavicle fracture fixation using Scorpion Plate ^®.
Methods: Ten patients fixed by Scorpion Plate ^® from April 2010 to December 2011, and who were able to be followed up for more than 12 months, were evaluated. The mean age was 42.6, 8 were male and 2 were female. The average follow up period was 14.6 months. Duration of union, size of the fragment, range of motion and JOA score at 3 months and 6 months postoperatively were evaluated.
Results: All the fractures were classified as Type II by Neer Classification with an average fragment size of 33.6mm. Mean duration of union was 6.4 months, except for 1 case, which needed low intensity pulsed ultrasound because of delayed union. Flexion, abduction, external rotation (all in degrees) and JOA score (in points) at 3 months and 6 months postoperatively were 166/174, 166/176, 59/63, 95.9/98.8, respectively. Complication was observed in 1 case whose screw loosened 3 months postoperatively.
Conclusion: The results of distal clavicle fracture fixation using Scorpion Plate ^® were satisfactory. It is a very effective device for distal clavicle fracture, although you need to be cautious about damages caused by the plate.

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Background: There are various ways to treat a clavicle fracture. Conservative therapies are chosen in some cases and surgical therapies are chosen in other cases.There are several methods in surgical therapies. The purpose of this study is to investigate the clinical results of cannulated cancellous screw fixation for a clavicle fracture.
Methods: The cannulated cancellous screw fixations for transverse or oblique fracture of clavicle were performed on eight shoulders from 2011 to 2012. There were 8 males with an average age of 30.9 years old. There were 3 right sides and 5 left. The period from injury to operation was 7.0 days on average. Two cases were carried out using open surgery and 6 cases used percutaneous fixation. Sling and band fixations were used for about one week.
Results: Bone union occurred in all cases. The cannulated cancellous screws were removed in all cases 6.5 months on average after the operation of the reduction. The postoperative flexion angle was 178.8 degrees on average. The postoperative external rotation angle was 85.0 degrees and internal rotation was Th7.9 on average. The postoperative ranges of motion of their shoulders were mostly good.
Conclusion: The clinical results of cannulated cancellous screw fixation for a clavicle fracture were good.

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Background: Intramedullary pinning for midshaft claviclar fracture has been considered to be a less invasive surgery. But it becomes necessary to open a portion of the fracture when it cannot be reduced by closed procedure. The purpose of this study is to investigate the rate of closed and open reduction retrospectively, and evaluate the clinical results.
Methods: We evaluated 84 patients who were treated by intramedullary pinning at Japanese Red Cross Society Wakayama Medical Center from 2005 to 2011, and investigated the rate of closed and open reduction, the complications, and the duration of the bone union in closed group(C group) and open group(O group).
Results: The rate of closed reduction and open reduction was 64% and 36% respectively. Infection occurred in 5 shoulders (6%), irritation of K-wire caused by the wire's back out occurred in 8 shoulders (10%). No nerve, vessel, or lung injury was observed in any of the shoulders. The duration of the bone union was 74 days (36-159 days) in C group, and 90 days (41-191 days) in O group, which shows no statistical significance between two groups. Bone union was finally obtained with all shoulders.
Conclusion: We had to open a portion of the fracture in 36% of cases, but obtained the bone union in all shoulders and the duration of the bone union showed no statistical significance between C group and O group. Therefore we recommend that open reduction is an effective method when it is difficult to reduce by closed procedure.

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Background: Fracture of the proximal clavicle is relatively rare. There are few reports about their treatments. The purpose of our retrospective study is to report the results and features of the proximal clavicle fractures which were treated in our institution.
Methods: This series included 22 cases. There were 11 males and 11 females. The mean age at injurywas 60.8 years old. The mechanism of injury was; falls from height in 12 cases, motor vehicle accident in 5 cases, and simple fall in 5 cases. Twelve cases were complicated by other injuries at the shoulder girdle. Ten cases were not complicated by other trauma lesions . The Robinson classification of fractures was type 1A1 in 8, type1B1 in 11, type1B2 in 3 cases.
Results: Conservative treatment was attempted in 10 cases. Operative treatment was attempted in 12 cases. Seven of these ten conservative cases showed evidence of non-union. All cases treated operatively had good results without any hardware complication or non-union. The Robinson classification of the non union fractures was type 1A1 in 4 of 7 cases,(57%) type 1B1 in 2 of 2 cases(100%) and type 1B2 in 1 of 1 cases(100%). All conservative cases with other injuries at the shoulder girdle resulted in non union.
Conclusion: We considered type 1B fracture of the proximal clavicle, with any other injuries at the shoulder girdle should be treated operatively. Locking plate is safe hardware in surgical cases.

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