Background: In previous literature, the anterior (Ac) and posterior (Pc) circumflex humeral arteries were supposed to communicate with each other around the surgical neck of the humerus. However, actual anastomoses between these arteries were rarely observed. The purpose of the present study is examine the origins, courses, and distributions of Ac and Pc. Materials and Methods: We evaluated 44 shoulders from 25 cadavers including 21 right and 23 left shoulders. Results: In all specimens, Ac directly originated from the axillary artery, sent branches into the insertion of the subscapularis, and then, ascended along the long head of biceps. In some specimens, Ac passed under the long head of biceps. Pc originated from the axillary artery or the subscapular artery, and went around behind the humerus. Pc ran anteriorly from the middle to anterior portion of the deltoid sending branches into them. The diameter of the origin of Ac was an average of 1.7mm (SD; 0.4) and that of Pc was 3.5mm (SD; 0.9). The diameter of Ac was significantly smaller than that of Pc. Conclusion: There were no direct anastomoses between Ac and Pc through thick arteries, while they made anastomoses through a capillary vessel inside or outside the deltoid muscle. The running course of each artery was separated by the conjoined tendon, long head of biceps, pectoralis major and subdeltoid bursa. Based on the present results, Ac and Pc would not make a complementary relation, and each artery might have an independent function.
Background: It is difficult for young shoulder arthroscopists to get accurate orientation. The purpose of this anatomical study was to propose several spots around the glenoid as landmarks for the shoulder arthroscopy compensating for its narrow view field. Methods: The scapula of 15 embalmed shoulders was removed and the clock time positions of several structures around the glenoid were recorded in units of 30 minutes by two independent examiners. Interobserver variability was evaluated by κ statistic. Results: The average position of each structure between the two examiners were shown in order as viewed in the right shoulder; center of the attachment of the long tendon 11:59, anterior edge of the supraspinatus 11:59, border of the supra and infraspinatus 10:27, superior edge of the subscapularis 1:03, border of the infraspinatus and teres minor 7:43, inferior edge of the teres minor 6:21, inferior edge of the subscapularis 5:27, anterior edge of the coracoid process 1:25, posterior edge of the coracoid process 12:13, center of the scapula spine 10:06. κ statistic of the structures were ranged from 0.45 to 0.88 and the results were considered reproducible. Discussion: The results of this study showed the standard about the area of the rotator interval, borders of rotator cuff muscles and some osseous landmarks. These facts are useful, for example, in detaching torn rotator cuff from the scapula neck. This study would help beginners of shoulder arthroscopy to improve their learning curve.
Background: Normal motions of the ribs and scapula should be analyzed to identify costal and scapular dyskinesia in patients with idiopathic frozen shoulder. The purpose of this study was to investigate characteristics of their motions and compare the amount of translation or angle in 2 different aged groups. Methods: We recruited 33 normal subjects and classified them into 2 groups: younger (Y) group aged 20 years old (10 males, 7 females) and middle (M) aged group aged from 40 to 60 years old (8 males, 8 females). We took 3D-CT of the thorax in resting and 160° elevation positions, calculating the amounts of motion in all ribs, thoracic spine, and scapula. Scapular motion was evaluated with scapulohumeral rhythm (SHR). Results: The 5th rib remarkably translated in both groups. There was neither significant difference in the amounts of ribs, nor thoracic spine, motion between Y and M groups. SHR in Y group (3.0) was higher than that in M group (2.4). No differences were found in SHR of males between the 2 groups, however, SHR in females of Y group showed significantly higher than that of M group. Conclusion: The 5th rib showed the greatest amount of translation during arm elevation. There was neither significant difference in the amounts of ribs, nor thoracic spine, motion between Y and M groups.
Background: It is well known that the changes of rotation angles are decreasing of internal rotation angle (IRA) and increasing of external rotation angle (ERA) in the dominant shoulder of overhead athletes. However, it has not been studied how much the glenohumeral joint (GHJ) and scapulothoracic joint (STJ) affect them. The purpose of this study was to evaluate GHJ with CT images obtained at Zero position. Methods: 20 shoulders of 10 healthy volunteers (5 overhead athletes (the O group) and 5 non-overhead athletes (the N group), all men) were evaluated. CT images were taken with the arm in the maximum internal and external rotation at the Zero position in supine position. The range of motion (ROM) of GHJ and STJ joint were measured using 3D kinematic analysis. Results: The average IRA, ERA and ROM (dominant/non-dominant) of GHJ were 51.6 /64.6, 21.6/28.8 and 73.2/93.4 degrees respectively in O group. The average IRA, ERA and ROM of GHJ were 68/61.4, 26.4/40.6 and 94.4/102 degrees respectively in N group. Conclusion: IRA and ROM of the dominant GHJ in O group could be less than that in the N group.
Background: The objective of this study was to analyze the rotator cuff muscles and other 7 muscles activity simultaneously during shoulder abduction by utilizing electromyographic (EMG) analysis. Methods: Measurements were compared between full can and empty can exercise. Non-dominant shoulders of five asymptomatic male volunteers (21-34 y.o.) were investigated. Fine-wire EMG electrodes were inserted into supraspinatus (SSP), infraspinatus (ISP), teres minor (TM), and upper and lower part of subscapularis (SSCU and SSCL). Surface electrode EMG were collected from lattisimus dorsi(LD), deltoid anterior(DA), middle(DM), posterior(DP), pectralis major upper(PMU), lower(PML), and trapezius(TRAP). The EMG data were collected during abduction exercises on the scapula plane while holding 1kg dumbbell. The EMG value was expressed as a percentage of MVC (maximum voluntary contraction) of the corresponding muscle to standardize. Results: %MVC of DM was significantly higher with empty can exercise. DP and TRAP showed a trend that %MVC was higher with empty can exercise (P=0.07,0.08) than with full can exercise. In the cuff muscle, we could not see any statistically significant difference, however, %MVC was higher in the ISP, SSCU, SSCL, TM with empty can exercise. It is reported that contraction of SSP is not different between full and empty can position. Conclusion: In this study, the other cuff muscles (ISP,SSC,TM) showed higher %MVC with empty can exercise. The empty can exercise may be a good exercise to recruit the all cuff muscles.
Background: JOA score (JOA) is health professional side evaluation, but Shoulder 36 (Ver1.3) (Sh36) is patient basis evaluation. Although the reactivity of Sh36 and reliability were estimated by Maruyama, there were few reports of the relation between each item of JOA and Sh36. Methods: 101 shoulders which underwent arthroscopic surgery (Rotator cuff tear 67, shoulder instability 28, contracture 6) were investigated. Preoperatively, the rank correlation of Spearman examined the correlativity between pain, function, ROM and ADL of Sh36 to JOA. Moreover, the same examination was performed for each disease and disease singularity was also examined. Results: In all the cases, correlation of JOA and Sh36 was found in pain (P ‹ 0.01), functions (P ‹ 0.01), ROM( P ‹ 0.01) and ADL (P ‹ 0.01). On the other hand, in rotator cuff tear only correlation of JOA and Sh36 with function (P ‹ 0.01) and ROM (P ‹ 0.05) were found and in shoulder instability a correlation with function (P ‹ 0.05) was found. At shoulder contracture, correlation of JOA and Sh36 was found in no items. Conclusion: Correlation was found between each item of pain, a function, ROM, and ADL of JOA and Sh36 in all cases. However, there was no correlation in pain at rotator cuff tear and contracture, and there was in ROM at shoulder instability. It seems that more detailed shoulder joint evaluation of function can be performed by performing evaluation of JOA and Sh36 on both sides.
Background: The purpose of this study was to investigate the accuracy regarding palpation of the long head of biceps brachii tendon. Methods: Seventy four patients with 148-shoulders were employed in this study. A marking was performed on the skin after palpation, and success/miss palpation was judged with a ultrasonography. Distance between surface of the body and the long head of the biceps brachii tendon, width of the biceptial groove and the degree of obesity were calculated, and the concern between accuracy of palpation and these results was investigated. Results: The success rates were 100%, 100%, 92.9%, 50.0% and 15.0% in normal, obesity 1, 2, 3 and 4 degree, respectively and the differences were significant except between normal and obesity 1 degree. Distance between surface of the body and the long head of the biceps brachii tendon was deeper as the degree increased. There was no significant difference for the width of the biceptial groove. Conclusion: Palpation was difficult in obesity 3 and 4 degree, and the cause of this result may be the distance between surface of the body and the long head of the biceps brachii tendon. There was no relationship between the width of the biceptial groove and accuracy of palpation.
Background: The Japanese Orthopaedic Association (JOA) shoulder scoring system (JOA score) has been used of clinical evaluation for shoulder disease. Currently Shoulder evaluation sheet Shoulder 36 (Sh36) has been introduced as a new evaluation system, though the differences and similarities between these two clinical evaluations is not well known. The purpose of this study was to evaluate correlations between Sh36 and JOA score; assess clinical significance in Sh36. Methods: We evaluated 40 shoulders in 40 consecutive patients (18 male, 22 female) who had arthroscopic shoulder surgeries. Average age at the surgery was 59.0 years. Forty shoulders were divided into 3 disease groups: 22 cases of impingement syndrome, 11 cases of rotator cuff tears and 7 cases of stiff shoulders. Preoperative clinical evaluation was performed with both Sh36 and JOA score; correlations between domains, disease groups and gender in the two clinical evaluations were statistically evaluated. Results: Each domain (Pain, ROM, Muscle strength, General health and ADL) has significant correlation between Sh36 and JOA score. A relatively weak correlation was observed at ROM domain in all three disease groups. Pain, Total and ADL scores have significant correlations in male patients. Pain, Muscle strength and ADL scores have significant correlations in female patients. Conclusion: Significant correlations between Sh36 and JOA score were observed except for ROM domain; Sh36 was recognized as a clinically useful evaluation system.
Background: Preoperative assessment including the glenoid morphology and soft tissue pathology is a key to success for surgical intervention for traumatic anterior glenohumeral instability. Although examination under anesthesia is still a standard procedure for the measurement of the instability, we incidentally detected the anterior shift of humeral head in the routine modified Bernageau view in patients with anterior glenohumeral instability. The purpose of this study is to investigate the effectiveness of this method for the assessment of anterior instability. Methods: 302 patients underwent an arthroscopic stabilization for anterior glenohumeral instability between 2010 and 2011. Exclusion criteria were as follows: Patients who have multidirectional instability, instability in both shoulders, history prior surgery, Patients unable to take the modified Bernageau view for apprehensive sensation. Therefore 169 patients were included in this study, with an average age of 25.7 years. We calculated the average ratio of anterior translation of the center of humeral head in both shoulders. The values were compared between the normal side (G/R) and the affected side (G'/R'). Mann-Whitney's U test was utilized for statistical analysis. The significant value was established at p ‹ 0.05. Results: The average ratio of anterior translation of the humeral head was 0.319 on the affected side and 0.252 on the contralateral side. The value in affected side was significantly higher than that on the contralateral side (p ‹ 0.01). Conclusion: The modified Bernageu view shows significant anterior translation in patients with traumatic anterior glenohumeral instability. These results suggest the modified Bernageu view is a useful procedure to evaluate anterior instability by a simple X-ray.
Background: The conventional measuring method for glenoid version is sensitive to the scapular body shape. Because of its variation, the scapular body shape greatly affects the value of the version. Thus, the glenoid vault version could be more useful in clinical cases than the conventional glenoid version. We hypothesized that the two measuring methods would give different values of the version and that the glenoid vault is more retroverted than ever thought. Methods: Axial computed tomography scans of bilateral shoulders from 165 healthy volunteers and 150 shoulders with primary glenohumeral osteoarthritis were used in this study. The values of glenoid version measured with the conventional method and vault method were examined in normal and arthritic shoulders. Differences between the two methods were analyzed. Results: Both measuring methods showed excellent inter-rater and intra-rater reliability. The glenoid had 0.7+/- 4.1° anteversion with conventional method and 7.2 +/- 3.3° retroversion with vault method in normal shoulders. In arthritic shoulders, the average glenoid retroversion was 11.7 +/- 9.3° measured with conventional method and 16.8 +/- 8.9° with vault method. Glenoid retroversion measured with vault method was significantly larger than that with conventional method. Conclusion: Glenoid vault version could be useful as an alternative method for measuring glenoid version with excellent reliability and lower standard deviation compared to the conventional glenoid version. The glenoid vault is usually retroverted without the influence of the scapular body shape.
Background: It is difficult to diagnose the subscapularis tendon tears preoperatively. The purpose of our study was to evaluate the relationship between the subscapularis tendon tears and the bone cysts in the lesser tuberosity on CT. Methods: We evaluated 107 shoulders (64 males and 43 females, 68 right and 39 left shoulders) who had both CT arthrography and arthroscopic rotator cuff repairs performed. Their average age was 64.4 (35-83) years old. The cysts were evaluated with both transverse and parasagital images on CT arthrography. Results: Bone cysts in the lesser tuberosity were identified in 27 of 107 shoulders (25.2%). The arthroscopic findings showed subscapularis tendon tears in 57 shoulders (53.3%) which included 29 articular-sided tears, 1 bursal-sided tear, 27 complete tears. With regard to the relationship between subscapularis tendon tears and the bone cysts in the lesser tuberosity on CT, the sensitivity was 40.4%, the specificity was 92.0%, the accuracy was 64.5%, the positive predictive value was 85.2%, and the negative predictive value was 57.5%. Conclusion: The presence of bone cysts in the lesser tuberosity on CT strongly suggested subscapularis tendon tears. CT or CT arthrography is useful for preoperative diagnosis of subscapularis tendon tears.
Background: Preoperative evaluation of bone microstructure is of utmost importance because, especially in elderly patients, osteoporotic change causes anchor pullout problem, which results in failure of rotator cuff (RC) repair. In this study, using Multi-Detector row CT (MDCT), we have successfully performed in vivo evaluation of bone microarchitecture of the tuberosities of the humeral head in patients with RC tears. Methods: Fifteen cases with RC tears were examined. The region of interest (ROI) was defined in six quadrants (medial and lateral rows of anterior, middle, and posterior quadrant) within the greater tuberosity (GT) of the humerus. Each quadrant had an identical cylindrical shape with a diameter of 5.0 mm and a depth of 15 mm, and was placed at a 45° angle to the GT. Morphometric parameters including mean bone volume to total volume (BV/TV), trabecular thickness (Tb.Th), trabecular separation (Tb.Sp), and structure model index (SMI) were measured using a bone analysis software and statistically assessed. Results: The value of BV/TV of the posteromedial quadrant was the highest among the values of all other quadrants.The value of SMI was the lowest among those of the other quadrants. Conclusion: Based on the values of BV/TV and SMI, we found that bone quality of the posteromedial portion was the highest within the GT of our patients. Since the bone quality may correlate to the pullout strength of suture anchors, our method can be useful to determine the best position to implant suture anchors in patients with RC tears.
Background: There were a few morphologic studies, which investigated in the cuff tear arthropathy (CTA) in Japanese. The purpose of this study is to investigate whether there are any characteristic changes of the primary CTA with CT scans. Materials: CT scans were obtained of 49 shoulders with CTA of the glenohumeral joint. The measurement was performed at the middle level of the glenoid. Glenoid morphology was assessed qualitatively by measurement of the glenoid retroversion using the technique reported by Friedman et al (1). Morphologic changes of the glenoid were evaluated by Walch's classification (2) as follows; Type A was characterized by a well-centered humeral head and a balanced distribution of strengths against the surface of the glenoid. The erosion may be minor-type A1 or major-type A2. In Type B, the posterior subluxation of the humeral head was responsible for the asymmetric load against the glenoid, particularly the exaggerated posterior wear pattern: B1 showed narrowing of the posterior joint space, subchondral sclerosis, and osteophytes, and type B2 demonstrated a posterior cupula that gave an unusual biconcave aspect to the glenoid. Type C was defined by a glenoid retroversion of more than 25 degree. Results: Mean Glenoid retroversion was 2.7 ± 5.3°. Morphology was classified as follows; 68% classified in type A, of them A1 in 27% and A2 in 41%. 32% in type B, of them B1 in 29% and B2 in 3%, none in type C. Conclusion: There are some difference in morphologic study between CTA and the primary glenohumeral osteoarthritis.
Hypothesis: Magnetic resonance imaging is useful for evaluating the rotator cuff, but some tendinous insertions cannot be assessed using conventional oblique coronal and axial imaging due to the presence of partial volume effect. The purpose of this study was to determine whether radial-sequence magnetic resonance imaging could visualize normal rotator cuff insertions and rotator cuff tears more clearly than standard imaging. Methods: Subjects comprised 20 patients with a normal rotator cuff and 20 patients with rotator cuff tears. Fat-suppressed T2-weighted imaging of rotator cuff insertions sliced into radial, oblique coronal and axial sections were obtained. The extent to which normal rotator cuff insertions were visualized in each of the three images, and the extent of rotator cuff tears in radial and oblique coronal images were then compared. Results: Radial images could visualize anterior portions of rotator cuff insertions from 0° to 22.9 ± 7.1° and from 45.0 ± 5.4° to 109.1 ± 9.6°, and posterior portion from 0° to 116.3 ± 8.3°. In comparison, oblique coronal images could visualize 0° to 20.3 ± 9.1° of anterior and 25.1 ± 5.6° of posterior portions, while axial images visualized 63.4 ± 7.5° to 109.1 ± 9.6° of anterior and 72.0 ± 9.5° to 105.0 ± 6.9° of posterior portions of rotator cuff insertions. Radial images also visualized a greater posterior area of rotator cuff tears than oblique coronal images. Conclusion: These findings demonstrate that radial-sequence magnetic resonance imaging is superior to oblique coronal and axial imaging, due to the ability to accurately visualize all rotator cuff insertions. Radial imaging is particularly good at visualizing clinically important posterior rotator cuff tears.
Background: MRI is the imaging modality of choice for demonstrating pulley lesion. However, there are few reports about diagnosis of pulley lesion by MRI. The purpose of this study was to examine the diagnostic rate of pulley lesion by plain MRI. Methods: MRIs were obtained on 25 patients who underwent arthroscopy from 2010 to 2012. Several signs that were hypothesized to be helpful in diagnosing pulley lesion were evaluated. Nonvisibility or discontinuity of the SGHL and anterior displacement of the LHB were assessed on parasagittal slice before LHB enter the groove in MRI. In addition, the position of the LHB was assessed on transverse slice. Subluxation of the LHB was defined as displacement over the inner rim of the intertubercular groove with remaining partial contact to the groove. Sensitivities, specificities and accuracies were calculated. Results: In MRI findings, we diagnosed pulley lesion in 9 shoulders, while in arthroscopic findings, we revealed pulley lesion in 11 shoulders. Sensitivity was 81%, specificity was 85% and accuracy was 85%. Discussion: Diagnostic rate of pulley lesion with MRI had a high accuracy in this study. To our knowledge, two reports of Weishaupt and Shaeffeler have focused on preoperative diagnostic imaging for pulley lesion. According to their study, MR arthrography provides high accuracy in the evaluation of the pulley lesion. In this study, we obtained the above result by plain MRI. Consequently, preoperative standard MRI findings are helpful for diagnosis of pulley lesion.
Background: Magnetic resonane arthrography (MRA) is a useful tool for detecting shoulder joint pathology. Gadolinium (gadopentate) provide superior image contrast, but it is not registered for intra-articular use in Japan. The purpose of this study is to investigate the usefulness of MRA without gadolinium. Methods: Forty shoulders were evaluated including 18 anterior instability and 22 throwing injuries. Mean age was 26.6 years (15-52), 6 female and 34 male. Thirty shoulders were evaluated by MRA using 15 ml of saline with 5 ml of 1 % lidocine (S group) and 10 shoulders using 20ml of diluted gadolinium (concentration 0.25 nmol/ml). Low-field open MRI (0.3T) was used. Three orthopedic surgeons diagnosed Fat-suppressed T1-weighted images (G group) and Fat-suppressed T2-weighted images (S group), individually. Two surgeons were blinded for the clinical information about patients. Results: Interexaminer agreement between three surgeons was 93 % of Bnakart lesion, 90 % of SLAP, and 53 % of the partial rotator cuff tear in S group. The rate of agreement of the Banakart or SLAP is significantly superior to rotator cuff lesion. Interexaminer agreement was 93 % of the Bnakart lesion, 90 % of the SLAP, and 70 % of partial rotator cuff tear in G group. There was no significant statistical difference between S and G group. There were no difficulties in detecting ALPSA (anterior labroligamentous periosteal sleeve avulsion) or capsular tear. Conclusion: MRA using saline is a useful clinical tool, especially for shoulder labrum pathology. It is possible to diagnose the shoulder instability by MRA without gadolinium injection.
Background: The combination of shoulder dislocation, rotator cuff or greater tuberosity fracture and axillary nerve damage is serious injury of the shoulder. We aimed this study to analyze our twelve cases of such a terrible association. Methods: Clinical findings, MRI, and EMG records of patients were reviewed retrospectively to identify patients with a combination of all three injuries. Patient demographics, EMG results, operative findings, postoperative recovery and follow up were recorded. Results: From 2004 to 2010, twelve patients (11 males and 1 female) of the terrible triad of the shoulder were treated at our hospital. Five had dominant and seven non-dominant sides injured. Ten patients underwent some surgeries and two patients had conservative management after initial manual reduction. Conclusion: Early diagnosis and timely surgical intervention along with a good rehabilitation program can improve the functional outcome of such a serious injury to the shoulder.
Background: We performed modified Neviaser's procedure for acromioclavicular dislocation. We evaluated postoperative radiographs of cases which had modified Neviaser's procedure performed. We performed this method on 23 cases, 18 males and 5 females, from April 2006. The age of the cases ranged between 20 and 73 years old (mean 37.3 years old), and 8 cases were classified in Rockwood type III and 15 cases were Rockwood type V. Methods: We evaluated radiographs to determine whether dislocation appeared again or not after operation. Results: All cases had a complete reduction after operation but 22 cases had a subluxation of acromio-clavicular joint at last examination. Of these 22 cases, 16 cases (5 cases in type III, 11 cases in type V) had a severe subluxation. Almost all cases had a subluxation after we removed Kirshner wire using acromio-clavicular joint fixation. Conclusion: The result suggests that the fixation between clavicle and coracoid process may be effective to keep the reduction of acromio-clavicular joint. The improvement of the surgical technique is necessary.
Background: Various surgical techniques have been reported for acromioclavicular joint (ACj) dislocation, with the clinical outcomes mostly being good to excellent. However, in practice, upward migration of the distal end of the clavicle is often noted after the removal of hook plate. The purpose of this retrospective study was to compare the radiographic outcomes of shoulders treated with hook plates. Methods: Sixty-one patients were surgically treated with hook plate. Preoperative dislocation after Rookwood's classification were Type III (35 patients), Type IV (4 patients), Type V (22 patients). They were divided into 3 groups as follows; Hook plate fixation only (38 patients), hook plate fixation with coracoclavicular (CC) ligament repair (18 patients), hook plate fixation with reconstruction of CC ligament (5 patients). The distance between the inferior margin of acromion and clavicle (AC distance) measured on A-P view of plain Xp before and at the final follow up were as follows. Results: AC distance of the 3 groups were as follows, hook plate fixation (13.4 ± 4.2mm before surgery and 1.5 ± 2.9mm at final follow up), hook plate fixation with the CC ligament repair (14.3 ± 4.8mm and 0.2 ± 1.1mm), hook plate fixation with CC ligament reconstruction (16.8 ± 5.6mm and 1.3 ± 2.1mm). The time to the hook plate removal was 16.4 ± 3.7 weeks in hook plate fixation only, 15.7 ± 4.1 weeks in hook plate fixation with the CC ligament repair, 15.3 ± 1.4 weeks in hook plate fixation with CC ligament reconstruction. There were two complications of bone erosions and distal end clavicle bone resorption. Conclusion: There was no significant difference between hook plate with or without ligament repair / reconstruction. However hook plate with ligament repair / reconstruction showed a tendency of less upward migration after plate removal.
Background: Although numerous operations for acromioclavicular joint dislocation have been reported, most of them cannot prevent correction loss and osteoarthritis after surgeries. We summarize the clinical results of our coracoclavicular ligament repair with temporary subacromial acromioclavicular fixation without penetration of the joint for acromioclavicular joint dislocation. Methods: For the treatment of severe acromioclavicular joint dislocation, we have repaired the coracoclavicular ligaments with temporary acromioclavicular joint fixation using 2 Kirschner wires. We included the 22 cases, which were followed up for more than 6 months after the surgeries in this study. In the first 14 shoulders, the wires had penetrated the acromioclavicular joint for 7 weeks (trans AC group). In the last 8 cases, we kept the wires passing under the acromion without penetration of the joint for 12 weeks (subacromial group). The clinical symptoms and radiographic findings at the final follow-up were analyzed and the two groups were compared. Results: The average postoperative coracoclavicular distance and acromioclavicular joint dislocation ratio were reduced in both groups. The improvements in both of these were significantly better in the subacromial group compared to the trans AC group. Seven cases in the trans AC group showed osteoarthritic changes of the acromioclavicular joint, but no arthritis was found in the subacromial group. Discussion: We concluded that the repaired ligament might not have the enough strength to hold the upper extremity weight in less than 3 months. Temporary acromioclavicular fixation under the acromion is suitable for long time fixation and can possibly prevent postoperative arthritis.
Background: The purpose of this study was to analyze clinical outcomes of arthroscopic coracoclavicular ligament reconstruction using a synthetic ligament for acute dislocation of the acromioclavicular joint (ACj). Methods: Ten patients with acute ACj dislocation, whose mean age was 43.3 years old, were the subjects of this study. According to Rockwood's classification, type 3 was observed in 7 patients and type 5 in 3 patients. Surgical procedure is as follows: the arthroscope is placed into the undersurface of the coracoid process (CP) through the subacromial bursa from an anterolateral portal. A 2-cm skin incision is made over the conoid tubercle of the clavicle. The drilling guide is set between the undersurface of the CP and the clavicle, and a 4.5 mm bone tunnel is made using a canulated drill. A synthetic ligament with an endobutton is passed through the bone tunnel, and the endobutton is anchored on the undersurface of the CP. The ligament is fixed on the clavicle by staples or interference screws. Clinical outcomes were assessed using the JSS-ACj score and postoperative X-rays. The follow-up period was 54.5 months on average. Results: Postoperative JSS-ACj score was an average of 97.2 points. Postoperative subluxation of the ACj was observed in two patients at the final follow-up period. Conclusion: Conventional open methods for ACj dislocation violate soft tissues such as muscles and ligaments. This arthroscopic method can avoid the large skin incisions and invasion of the soft tissues, and provide cosmetic satisfaction and anatomically solid reconstruction of the ACj.
Background: In our previous study, we evaluated the postoperative stabilizing effect of the inferior glenohumeral ligament-labral complex (IGHL-LC) in patients with anterior shoulder instability using ABER MRI. The purpose of this study is comparison of this effect between 6 and 12 months after the surgery. Methods: Thirty-nine consecutive patients who had ABER MRI taken at 6 and 12 months after arthroscopic Bankart repair were enrolled in this study. We calculated the position of humeral head center (HHC) relative to the glenoid center, the inclination of IGHL, and compared them between 6 and 12 months after the surgery. Results: The HHC was -8.7 +/- 6.9%, -7.4 +/- 5.7% and the inclination of IGHL was 3.6 +/- 9.0 degrees, 4.6 +/- 8.2 degrees at 6 and 12 months, respectively. The pattern of change of HHC was classified into 3 groups. Group 1: The HHC was located posteriorly and did not translate significantly. The inclination of IGHL also did not change significantly. Group 2: The HHC was located posteriorly at 6 months but it translated anteriorly at 12 months. The inclination of IGHL significantly increased. Group 3: The HHC was located anteriorly and the inclination of IGHL was larger than other groups at 6 months. Conclusion: The repaired IGHL-LC provided good stabilizing effect in group 1. The reason for anterior translation may be stretched IGHL in group 2 and 3.
Background: JuggerKnot anchorTM is a new unique suture anchor and the drill hole for anchor is small (1.4mm). However, some shoulders showed enlargement of anchor holes in radiographs taken postoperatively. The purpose of the present study was to radiographicallay evaluate the enlargement of anchor holes after the use of JuggerKnotTM anchors for arthroscopic capsulolabral repair in traumatic shoulder instability. Methods: 37 shoulders (28 males and 9 females, average age: 22) who underwent arthroscopic capsulolabral repair using JuggerKnot anchorsTM for traumatic anterior shoulder instability were included in this study. Anchor holes identified in radiographs taken at 3 to 4 months postoperatively were defined as "enlarged" or as "nonenlarged". To assess the site of enlarged anchor holes, we defined the anchor holes from 12 to 3 o'clock as "upper anchor holes" and from 3 through 4:30 as "lower anchor holes" in the right shoulder. Results: Enlargement of anchor holes was noted in 12 shoulders (6 males (17%) and 6 females (66%)) from radiographs taken at 3 to 4 moths postoperatively. Enlargement of anchor holes was noted in 32 out of 190 total anchor holes (16%), 22 out of 106 upper anchor holes (21%) and 10 out of 84 (12%) lower anchor holes. Conclusion: Enlargement of anchor holes was noted 16% of total anchor holes from radiographs taken on 3 to 4 moths postoperatively. Further investigation is needed to elucidate this topic because anchor hole enlargement could represent the possibility of anchor loosening and recurrence of instability.
Background: The purpose of this study was to evaluate the clinical results in sports players after modified Bankart and Bristow procedure for traumatic anterior shoulder instability. Methods: Seventy-four shoulders of 68 sports players were enrolled in this study, overthrowing sports (groupT): 11 shoulders, overhead sports (groupO); 7, collision sports (groupCL): 24, contact sports (groupCT): 22, and winter sports (groupW):11. Our surgical indication of modified Bankart and Brisrow procedure was that glenoid bone loss was more than 25% or we cannot lift up AIGHL to articular surface. We evaluated clinical outcomes by JSS-SIS and JSS-SSS score, level of return to sports activities, the recurrence rate of dislocation and satisfaction level. Results: Postoperative JSS-SIS and JSS-SSS score were improved significantly in all groups. Although all patients returned to pre-injury sports, the complete return rate was group T: 81%, O: 57%, CL: 85%, CT: 84%, W: 81%. Especially, return to pre-injury sports of dominant hand in group T and O was low (44%). Recurrence occurred in 1 shoulder in group CL, recurrence rate in all were 1.7%. Satisfaction was group T: 37%, O: 86%, CL:91%, CT: 76%, W: 73%. Discussion: In this study, recurrence rate was low and all players returned to pre-injury sports. 91% of collision sports players were satisfied with the outcome of their surgery, so we think B&B procedure is indicated for collision sports players. But clinical results in overthrowing and overhead sports players when it involved their dominant hand, were worse than that in collision sports players, and limitation of ROM remained. We think a procedure that can preserve ROM is indicated for overthrowing and overhead sports players when it involved their dominant hand.
Background: The purpose of this study was to evaluate the outcome of arthroscopic Bankart repair for traumatic anterior shoulder instability in sports players. Methods: 82 shoulders of 82 sports players were enrolled in this study, over-throwing sports; 11 shoulders, over-head sports; 17 shoulders, collision sports; 23 shoulders, contact sports; 21 shoulders, and winter sports; 10 shoulders. We evaluated clinical outcome by the JSS score, level of return to sports activities, the recurrence rate of dislocation, satisfaction level, and complications. Results: Postoperative JSS score was significantly improved in all sports. Satisfaction was found to be over-throwing sports; 63.6%, over-head sports; 76.5%, collision sports; 60.9%, contact sports; 80.1%, winter sports; 90.0%. Re-dislocation occurred in 2 shoulders in over-throwing sports, 4 shoulders in collision sports, 1 shoulder in contact sports, 1 shoulder in winter sports. There were no postoperative complications. Discussion: In our study, clinical results of over-throwing and collision sports are inferior to over-head, contact, and winter sports. We must sufficiently understand each game feature and select the surgical procedure(open or arthroscopy) depending on the needs of patients.
Background: For a successful outcome of arthroscopic Bankart repair, it is necessary to insert a suture anchor inside the glenoid bone. The purpose of the present study was to measure the angle and placement of bone holes for the anchors from postoperative computed tomography (CT) scans of scapula. Methods: Ten shoulders of nine consecutive patients (six male, 3 female; mean age: 25.4) who underwent arthroscopic Bankart repair were involved. All anchors were inserted through the anterosuperior portal after establishing a bone hole by drill. CT images of the scapula were taken within 18 months postoperatively. After creating 3-D scapula models from those data, all bone holes were divided into 2 groups: Success (S) group which was placed inside the glenoid bone till the end point, and Failure (F) group which penetrated the glenoid bone. In addition, the angle between glenoid articular surface and the bone hole were measured at the coronal and the transverse plane views. Results: A total of 40 drill holes were investigated in the inferior area. The penetration was shown in all the four holes (100 %) in posteroinferior area and six holes of the 18 holes (33.3%) in anteroinferior region. The angle at coronal plane view in S group was significantly larger than F group, whereas no significant differences were noted in the transverse plane view. Conclusion: A drill hole should be created carefully around posteroinferior position. Furthermore, the angle between drill guide and the glenoid surface at the coronal plane view should be given attention during the operation.
Background: This new anchor has advantage of easiness to re-insert during surgery and revision surgery and of being able to be inserted in a narrower space because of small diameter. Methods: We devided 110 cases of Arthroscopic Bankart repair into two groups. Group A is 86 cases using PLLA made anchor and PEEK made anchor. Group B is 24 cases using PEEK made anchor and polyester made anchor. The result of pull out test by 40 lb pull out strength during surgery, JSS score, ROWE score and degree of osteolysis measured by 3D CT were evaluated. Results: The pre-operative JSS score of group A was 38 and post-operative score was 84. The score of group B was 42 and 91 respectively. The pre-operative Rowe score of group A was 12 and post-operative score was 81. The score of group B was 18 and 88 respectively. There were no statistically significant difference for JSS score, Rowe score nor degree of osteolysis between two groups. There was no pull out case under 40 lb pullout test. I received no conflict of interest. Conclusion: The short term result of the new polyester-made anchor for arthroscopic Bankart repair can get the same clinical result when compared with PEEK or PLLA made anchor.
Background: The purpose of this study is to investigate the clinical features in patients with recurrent anterior dislocation of the shoulder associated with rotator cuff tear. Methods: 69 patients who had undergone arthroscopic surgery for anterior dislocation of the shoulder were investigated from January 2007 to December 2010. These patients were investigated using pre-surgery medical history and physical examination and inspected by MRI and CT arthrogram. Results: 5 patients were diagnosed preoperatively as Bankart lesion and rotator cuff tear. In this study clinical result was evaluated by JOA score. These patients were 3 males and 2 females, with an average age of 44.0 years old. Bony Bankart lesion was identified in all 5 cases. Physical examinations and image studies (CT and MRI) showed supraspinatus tendon tear. 4 cases had not only anterior but inferior instability of the shoulder explained by sulcus sign. It was decided preoperatively to repair both Bankart lesion and rotator cuff tear and simultaneous arthroscopic Bankart repair and rotator cuff repair was performed in all 5 cases. All 5 cases were followed at least 1 year after operation, no episode of shoulder dislocation was seen. The average JOA score was improved from 78.9 point pre-operatively to 95.9 post-operatively and little limitation of ROM of the shoulder was recognized. Conclusion: We considered that sulcus sign is one of the important factors in the decision to repair a cuff tear in a patient with recurrent anterior shoulder dislocation.
Background: We investigated the useful biomaterials for the purpose of regeneration of the soft tissues of traumatic instability of the shoulder joint. Based on experimental study, the polyglycolic acid sheet (PGA sheet) was the most suitable material for the regeneration of the soft tissues of the traumatic instability of the shoulder joint. We clinically used the PGA sheet for the regeneration of the anterior bundle of inferior glenohumeral ligament complex (AIGHL complex) in cases of traumatic instability of the shoulder joint. Methods: From 2000, we performed arthroscopic Bankart repair on 330 traumatic instability cases. Out of the 330 cases, we experienced twenty cases whose capsule and AIGHL complex became thin compared with uninjured cases. 15 cases were male, 5 cases were female. The average age was 24.1 years old. The average number of times of dislocation was 5.3 times. We grafted the PGA sheet to the injured site arranging the size of the graft to adapt to the injured site. We evaluated the clinical results using JSS shoulder instability score. Results: The average JSS shoulder instability score improved from 41.3 points preoperatively to 93.5 points postoperatively. We did not experience redislocation cases. There was no difference in the external rotation compared with the uninjured side. Discussion: There were few reports of the clinical usage of biomaterials for the regeneration of the soft tissues. We applied the PGA sheet for the purpose of regeneration of the AIGHL complex. The clinical results using biomaterials were preferable.
Background: The purpose of this study is to evaluate clinical results of arthroscopic Bankart repair (ASBR) with a minimum of one-year follow-up and to perform statistical examination to find some factors that affected postoperative outcomes. Methods: We retrospectively investigated 47 patients (49 shoulders), who underwent ASBR using bioabsorbable suture anchors, for traumatic anterior shoulder instability with a minimum of one-year follow-up. 1 case who had recurrence after ASBR was excluded. The pre and postoperative Japanese Shoulder Society shoulder instability score (JSS-SIS) and Rowe score, and the range of motion of external rotation in external rotation at side (ERS) and external rotation at abduction (ERA) were mainly evaluated statistically. Results: The ANOVA analysis showed that the higher the age at ASBR, or the longer the period between primary dislocation and ASBR, significantly lowered the postoperative ERA. Multiple linear regression analysis revealed that an age older than 30 years old at ASBR significantly lowered the postoperative ERA and Rowe score, and the longer the period during primary dislocation and ASBR significantly lowered the postoperative ERS and JSS-SIS. Conclusion: This study suggested that the ASBR performed earlier would show better outcomes. Further investigation will be required.
Background: The purpose was to investigate the influence of the repetition of dislocation and/or subluxation on glenoid defect and bone fragment absorption of bony Bankart lesion in shoulders with recurrent anterior instability. Methods: 163 shoulders with recurrent anterior instability were examined by CT scan, and rates of glenoid defect and bone fragment absorption were measured. First, their configurations of the glenoid were compared with those of 60 shoulders with primary instability. Then, their correlation with the number of dislocations and subluxations (total number) and the number of dislocations was investigated. Finally, they were classified into 4 groups according to the presence of glenoid defect and the grade of bone fragment absorption (A: no glenoid defect, B: bone fragment absorption less than 50%, C: more than 50%, D: 100% absorption), and the total number and the number of dislocations were compared. Results: While in recurrent cases glenoid defect was seen in 108 shoulders, and mean rate of glenoid defect was 11.3%, in primary cases they were 12 shoulders, and 3.5 %, respectively. While the rates of glenoid defect and bone fragment absorption were significantly higher in shoulders with the total number more than 10 times than in those less than 10 times, the number of dislocation did not affect them. As the mean total number was 4.5 times in A, 9.9 in B, 15.2 in C, and 19.0 in D, there was significant difference. Conclusion: As glenoid defect and bone fragment absorption deteriorated with the repetition of dislocation and/or subluxation, it was important to evaluate by CT preoperatively.
Background: Traumatic anterior shoulder instability has a wide spectrum, from a definite dislocation to a subtle instability. Most patients have the sensation that their shoulders slipped out at the time of instability events. There is, however, another category of patients who are not aware of slipping out or instability of the shoulder. The purpose of this study was to evaluate the characteristics of such patients who have not recognized traumatic anterior instability. Methods: Seventeen patients who were not aware of traumatic anterior shoulder instability were operated on between 2007 and 2011. There were 16 men and 1 woman, and the mean age at surgery was 18.8 years old. All patients except one case, engaged in contact sports or overhead sports activities. We investigated their clinical history, and both imaging and arthroscopic findings of their shoulders. Results: Chief complaints of the patients were recurrent shoulder pain during sports activities after a history of trauma. None of them felt that their shoulder had anterior instability or got unstable after the injury. Positive anterior apprehension test and positive relocation test led us to a suspicion that patients may have had recurrent anterior subluxation of the shoulder. CT and MR arthrogram revealed that there was evidence of anterior instability such as Bankart lesion and/or Hill-Sachs lesion. Arthroscopic examination confirmed these findings and anterior stabilization procedure yielded favorable outcomes. Conclusion: Attention should be paid not to miss the diagnosis of unstable painful shoulder in young athletes.
Background: The purpose of this study was to evaluate the clinical results of open reduction and internal fixation with locking plate (LP) for proximal humeral AO/OTA type C fractures. Methods: 22 type C fractures in 22 patients (mean age 67.8 years, eight male, fourteen female) treated with LP from 2001 to 2010 were included in the study. The 22 fractures included six type C-1, nine type C-2 and seven type C-3 fractures. Locking Humerus Spoon Plate (LHSP ®) was used on six patients and Proximal Humeral Internal Locking System(PHILOS ®) was used on 16 patients in this study. The mean follow-up period was 15.1months (range 8-35). All patients were evaluated by JOA score and the angle of active elevation. Results: The mean JOA score was 82.1 and the mean angle of active elevation was 116.4 degrees. The mean JOA score was 88.2 in type C-1 fractures, 82.0 in type C-2 fractures, and 77.9 in type C-3 fractures were achieved. The mean angle of active elevation was 133.3 degrees in type C-1 fractures, 116.1 degrees in type C-2 fractures, and 102.1 degrees in type C-3 fractures were achieved. Four complications were encountered in four patients. Complications included redisplacement of the greater tuberosity in two patients, back out of the screw in one patient and osteonecrosis in one patient (typeC-3). Conclusion: Although the results of type C-3 fractures were inferior to type C-1 and C-2 fractures, the short term results of ORIF for type C proximal humeral fractures using LP were satisfactory.
Hypothesis: The purpose of the study was to show clinical results after operation using RUSH rods for fracture of the proximal part of the humerus. Methods: The study included 60 cases with 7 males and 53 females who were 61 years old on average. They included 39 cases of 2-part fracture, 17 cases of 3-part fracture, and 4 cases of 4-part fracture. Using anterolateral approach, the fracture site was opened and reduced. Two RUSH rods were inserted from the insertion of the rotator cuff tendon at the greater and the lesser tuberosities to fix the surgical neck. In cases with 3- or 4- part fracture, AO screws or sutures were used to fix the tuberosities. Each operation was done within 45 minutes on average. Pendulum exercise started within 10 days. They were evaluated both clinically and radiographyically 9 months on average after operation. Results: All cases showed bony union maintaining alignment after surgery. They gained 80 % of flexion, 74 % of abduction, and 60 % of external rotation, compared to their contra-lateral side. Nine cases could not adequately rotate their arm in elevation due to mal-positions of the proximal parts that were not reduced during operation. Conclusion: Our method was easy and less invasive. Two RUSH rods were adequate for maintaining the position. When anatomical reduction was done carefully, the method promised good clinical results.
Background: Minimally displaced greater tuberosity fractures are normally treated conservatively. However, some patients complain about refractory subacromial impingement even after obtaining bony union. The purpose of this study is to report on the clinical outcome after arthroscopic tuberoplasty for malunion following a greater tuberosity fracture of the humerus. Methods: Between April 2007 and July 2010, a consecutive series of 10 patients, with a mean age of 54.9 years, underwent arthroscopic tuberoplasty for refractory subacromial impingement and were followed for more than 1 year with a mean follow-up of 22.4 months. The mean duration before surgical intervention after initial injury was 9.2 months. Nine shoulders were classified as A1 and the rest as B1 with the AO classification system. Conservative treatment was chosen in all patients prior to the index surgery. All patients were placed in beach chair position under general anesthesia. The rotator cuff was detached from the greater tuberosity and then the tuberoplasty was performed, followed by reattachment of the rotator cuff using suture anchors. Results: Postoperative JOA and UCLA score improved significantly from preoperative 73.4 and 19.3 points to postoperative 93.8 and 33.1 points, respectively. Active forward flexion and external rotation at side also improved significantly from 123 and 33 degrees to 170 and 41 degrees, respectively. However, one patient developed postoperative selective external rotation deficit and underwent arthroscopic RATS procedure. Conclusion: Arthroscopic tuberoplasty for minimally displaced malunion after a greater tuberosity fracture is less invasive and a reliable procedure in terms of pain relief and functional recovery.
Background: Glenoid fractures of the scapula are rare. With inappropriate treatment, this injury can lead to post-traumatic degenerative joint disease and severe functional impairment. We report the clinical results of treatment of Ideberg typeII-V glenoid fractures of the scapula in our hospital. Methods: Between June 2005 and June 2011, seven Ideberg typeII-V glenoid fractures of the scapula were treated. There were 1 female and 6 males. The average age was 49.4 years old. There were 2 typeII, 2 typeIII, 1 typeIV, and 2 typeV cases. Indications for the operation included an articular step-off or gap of 5mm or greater, and disruption of superior shoulder suspensory complex(SSSC). The typeIV case was treated conservatively, and the remaining 6 cases were treated operatively. In operation, glenoid fractures and disrupted SSSC were repaired. We evaluated postoperative bone union, range of motion, step-off and gap of articular surface in CT view, and postoperative complications. Results: All fractures gained bone union. The average range of active elevation, external rotation, and internal rotation were 156.4 degrees, 48.6 degrees, and T10 level, respectively. The average step-off was 1.4mm, and the average gap was 0.8mm. There were no complications. Conclusion: Clinical results of treatment of Ideberg typeII-V glenoid fractures were satisfactory. In treatment of glenoid fractures, anatomical reduction of the articular surface and reconstruction of SSSC seem to be important.
Background: The purpose of this study was to report the clinical results of surgical treatment for ipsilateral Complex injury of the shoulder girdle. Methods: We studied five male patients who underwent surgical intervention and followed up for more than 6 months. The average age was 47.0 (28-63) years old and mean follow up period was 11.4 (6-15) months. Preoperatively, we evaluated the injuries using X-ray photo and 3D-CT. The injuries of the shoulder girdle were scapular body and clavicle shaft fractures in 3 cases, scapular body and coracoid process fractures with a fracture of distal clavicle in 1 case and comminuted scapular fractures with a dislocation of the acromioclaviclar joint (AC joint) in 1 case. The associated injuries were chest injuries including rib fractures, pelvic fractures, head traumas and ipsilateral fracture of upper extremity. Surgeries performed were osteosynthesis of unstable coracoid process or clavicle fracture alone for 4 cases and osteosynthesis of glenoid neck and scapular spine with fixation of AC joint for 1 case. Results: At the final examinations, all the patients got bone union and the mean JOA score was 94.8(83-100) points. Discussion: Several papers recommended a surgical treatment for unstable complex shoulder girdle injury including floating shoulder. It is difficult to evaluate such injuries with X-ray photo alone and 3D-CT image is necessary for correct diagnosis. Appropriate surgical treatments with accurate diagnosis of the ipsilateral complex injury of the shoulder girdle can lead to good clinical and functional results.
Background: The objective of this research is to survey the incidence and course of supraclavicular nerve injury following surgery for midshaft clavicular fractures. Methods: The study enrolled 30 patients who underwent surgery for midshaft clavicular fractures between 2009 and 2011 and who were observed for at least 3 months. The average observation period was 9.7 months (3--20 months). The surgery involved either plate fixation or percutaneous pinning. Plate fixation was used in 12 patients (6 males, 6 females) with an average age of 49.3 years at the time of surgery (16--73 years). Pinning was used in 18 patients (14 males, 4 females) with an average age of 36.7 years at the time of surgery (16--63 years). Patient consultation notes and medical records were used to assess whether these patients experienced postoperative hypoesthesia in the supraclavicular nerve region. Results: In the plate fixation group, 8 patients (67%) experienced postoperative hypoesthesia (of which, 3 patients experienced anesthesia). At the time of the final survey, 5 patients had made a full recovery, but 3 patients were left with mild hypoesthesia. In the pinning group, 3 patients (17%) experienced postoperative hypoesthesia, and 1 patient was left with hypoesthesia. Discussion: Supraclavicular nerve injury following clavicular fractures is thought to involve the type of injury received (direct external force delivered), the degree of dislocation at the fracture site, and iatrogenic injury. Particular care needs to be taken during surgery when plate fixation is selected.
Background: The purpose of this study was to determine whether hyaluronic acid (HA) could improve bone-tendon healing when applied to the repaired site. Methods: Complete tears of the infraspinatus tendon were made on bilateral shoulders of 24 Japanese white rabbits, and then, those were repaired immediately. Before skin closure, HA was applied to the repaired site on the right shoulder and phosphate-buffered saline on the left shoulder, as controls. Twelve animals were sacrificed at 4 weeks and another 12 animals were sacrificed at 8weeks postoperatively in each case: 9 animals were used for biomechanical testing and 3 animals for histological analysis. For biomechanical testing, ultimate failure load was calculated. The samples were embedded in paraffin and cut into 5-μm thick sections parallel to the tendon fiber. The slides were subjected to HE and Safranin-O staining. Chondroid cell layer formation and fibrovascular scar tissue at the re-formed insertion were evaluated. Results: All specimens failed at the tendon-bone interface. There were no differences of ultimate load to failure between the groups at postoperative 4 weeks: 52.7 ± 21.59N in the HA group and 52.95 ± 17.98N in the control group. At postoperative 8 weeks, it was significantly greater in the HA group than the control group (90.68 ± 16.04N and 66.97 ± 10.02N, P < 0.05). Fibrocartilage formation seemed not to be apparent between the groups at postoperative 4 weeks; however, it became evident in HA group at postoperative 8 weeks, with its anchorage between the tendon and the bone, compared with the control group. Conclusion: HA may accelerate the fibrocartilage formation in tendon-to-bone healing, with enhancement of the biomechanical property.
Background: Massive tear of rotator cuff is very difficult to care for and postoperative results are not always good. So, we perform semitendinous tendon and gracilis tendon graft for massive rotator cuff tear (ST • G graft). Our new changes are to make enough area of foot-print, to use suture bridge technique and to make tight control of ADL. Methods: From 2009 to 2011, we performed ST • G graft on 30 cases (31 shoulders), and all cases were followed over 6 months and had postoperative MRI taken. Re-rupture of rotator cuff was decided, when someone's postoperative MRI was classified to type 4 or 5 according to Sugaya's classification. We studied ROM of shoulder, shoulder score of Japanese Orthopaedic Society, Quick DASH, right or left side, percentage of male and age. We used t-test and chi-test to compare statistically. Results: There are 6 cases of Sugaya's type1, 16 cases of type2, 3 cases of type3, 2 cases of type4, and 4 cases of type5. Re-rupture rate of rotator cuff is 19.4%. It is a better results compared to our past series of ST • G graft for massive rotator cuff tear, that included 25% of re-rupture. Five of 6 cases, who were diagnosed as patients of re-rupture of rotator cuff were male and all 6 cases were right side. Conclusion: New technical changes of ST • G graft for massive rotator cuff tear can improve occurrence of postoperative re-rupture, although right side tear and being male are its risk factors.
Background: Intratendinous tendon suture is known as atraumatic tendon suture, because the blood supply at the tendon end is less interfered with. We have added this intratendinous tendon suture to the single-row rotator cuff repair. The purpose of this study was to evaluate the postoperative results of this suture technique. Methods: Forty-one patients with rotator cuff tears had cuff repair with the single-row repair and augmentation by the intratendinous tendon suture. The average age of the patients was 62.5 years old. The size of rotator cuff tear was as follows, incomplete tear and small tear: 6 shoulders, medium tear: 21 shoulders, large tear: 14 shoulders. The loop-shaped No.2 HiFi® suture was passed through the rotator cuff at the muscle-tendon junction. The edge of HiFi® suture was passed inside the loop, and the rotator cuff was grasped by the loop suture. The HiFi® suture was pulled out from the tendon end, and then passed through the bone tunnel at the greater tuberosity. After the cuff end was fixed to the greater tuberosity by single-row repair, HiFi® suture was fixed at the lateral aspect of the greater tubeosity. Results: At six months after the operation, the result was evaluated by MRI images with Sugaya's classification. Re-rupture (Type-IV) was detected in only three cases (7.3%). Conclusion: This suture technique, adding the intratendinous tendon suture to the single-row repair, might decrease the re-rupture of the rotator cuff repair.
Background: Since 2006, we have performed arthroscopic Surface-holding procedure, which is a modified transosseous-equivalent procedure, for rotator cuff tear. The objective of this study was to evaluate clinical results and postoperative cuff integrity of this procedure. Methods: One-hundred and three shoulders were included in this study. There were 63 men and 40 women, and the average age at surgery was 64.5 years old (range: 43-86). There were 1 incomplete, 10 small, 50 medium, 22 large, and 20 massive tears. At surgery, the footprint was medially advanced. The threads of medial anchors were passed through the tendon and, without tying, were pulled out to the distal cortex of the greater tuberosity. JOA score and cuff integrity on MRI using Sugaya's classification were evaluated. The average follow-up period was 16.7 months (range: 12-40). Results: The average postoperative JOA score was 92.5 points (66-100) in total, 94.7 points in small/medium tears, and 89.2 points in large/massive tears. The re-tear rate was 11.6% in total; 8.3% in small/medium tears and 16.7% in large/massive tears. Excellent or good score was obtained in 94% of well-repaired shoulders; whereas it was 50% in re-tear shoulders. Discussion: Arthroscopic Surface-holding procedure has several advantages: medial advancement of footprint to decrease tension to the repair site, no knot tying on the surface of cuff tendon to prevent re-tear at medial site, no usage of lateral anchors to avoid backout of an anchor in osteoporotic bone, and a wide contact area. As a result, low re-tear rate was observed especially in large and massive tears.
Background: Good results of the bridging suture technique (BST) for the rotator cuff tear have been reported. Although medial-row failure was a previously reported mechanism after double-row repair, there have been few reports on the evaluation about the BST. The purpose of this study was to compare clinical results of the BST using medial knot tying and non-tying. Methods: 36 patients were enrolled in the study. The first group (13males, 5 females, average age: 59.7 years old) had surgeries by BST with medial knot tying and the other group (13 males, 5 females, average age: 60.6 years old) had rotator cuff tears repaired by means of performing BST without medial tying. JOA score and Sugaya's classification were used for the evaluation. Results: In the tying group, JOA score was improved to 90.1 points. As for postoperative MRI findings, 1 case had type 4 and 1 case had type 5 of re-tear. In the non-tying group, the average postoperative score was 90.1 points, which was a significant improvement the same as the tying group. MRI revealed 1 case of type 4 and 1 case of type 5 re-ear remaining cuff with medial-row failure after re-tear visualized on the foot print in the tying group, which was different from non-tying cases. Discussion: The postoperative results of the cases with the BST were assessed. Although clinical results of medial knot tying group were almost same as non-tying group, it is suggested that medial concentration stress is considered to be one of factors of the re-tear mechanism.
Background: We can see an obvious X-ray change in shoulder joints with cuff-tear arthropathy, which results in severe joint damage with rotator cuff tear (RCT). It is difficult, however, to evaluate the nature of articular cartilage without progressive damage. Recently T2 mapping has been reported as a technique to examine cartilage quantitatively. The purpose of this study is to evaluate cartilage degeneration in the shoulder joint and the relationship of RCT. Methods: Forty two patients (25 males and 17 females, mean age of 63.6 years old) were evaluated. We analyzed routine MRI protocol and T2 mapping using the oblique coronal planes. T2 values of cartilage were examined at the region of interest established as superior (g1) and inferior (g2) site of glenoid and as superior (h1), middle (h2), and inferior (h3) site of humeral head. The medial displacement index (MI) and upward migration index (UI) were obtained using plain X-ray of the shoulder joint. Results: The T2 value at h3 was 47.5ms in MI higher group and 63.1ms in MI lower group, which was statistically significant. Thirty three shoulders had RCT, which included 8 shoulders with large and massive tears. The T2 value at h3 was significantly higher in the large and massive tear group than another group. Discussion: Kerr et al reported that they could detect bony spur and cyst formation at the lower part of humeral head in OA patients, which could be supported by our results.
Background: We often encounter problems in treatment of injuries caused by traffic accident. We experienced cases of rotator cuff injuries in which proper diagnosis and treatment was delayed. The purpose of this study is to investigate the clinical features and background of treatment in those cases. Methods: Twenty three patients (men 16, women 7, mean age 47.4) underwent surgical treatment and were investigated. All patients were drivers and types of accident were 14 rear-end collision, 8 side collision, and 1 fall down into the sea. The rotator cuff injuries included 4 cases of large tears of supraspinatus (SSP) + infrasupinatus + subscapuralis (SSC) tendon, 4 cases of incomplete tears of SSP and SSC, 6 cases of SSC tears, and 11 cases of rotator interval lesions (RIL). All cases were repaired under arthroscopy. The features of accidents, clinical findings, period between occurrence of accidents and diagnosis, and clinical outcomes were investigated. Clinical outcomes were evaluated according to JOA score. The average follow-up period was 2.7 years. Results: The average of period between occurrence of accident and proper diagnosis was 6.2 months. JOA improved from 46.5 to 92.6 points. All the patients with large cuff tears were over 60 years old, whereas patients with SSC teas or RIL were 30 to 50 years old. In 15 cases, more than 6 months was spent to get proper diagnosis. Conclusion: Shoulder injuries may be caused by even minor traffic accidents. Timely and proper diagnosis and treatment are necessary in patients with shoulder pain or functional disturbance.
Background: There is seldom report regarding to the relationship between trauma and rotator cuff tear. Methods: Patients who underwent rotator cuff repair between Sep. 2008 and Mar. 2011 were included in this study. All patients were evaluated by JOA score before and 1-year operation after. 65 patients, 67 shoulders were included. Age, trauma history, the period they had been symptomatic and JOA score were evaluated. These patients were divided into three groups: TR group as those who became symptomatic after direct trauma, TE group as those who became symptomatic after trifling episode, NT group as those who had no trauma. There were 14 patients (14 shoulders) who abducted actively below 90 degrees at first referral. Same evaluation was done separately for all patients. Results: JOA score was improved significantly after operation (p < 0.001). In all patients, there was no significant difference between three groups in age and JOA score before operation. Although there was significant difference between three groups in the symptomatic period, there was no significant difference between them in JOA score after operation. In the patients who abducted below 90 degrees, the patients in NT group tended to be symptomatic for a longer period. The patients in TR and TE group tended to have a better JOA score after operation than those in NT group regardless of rotator cuff size. Discussion: The trauma history itself didn't affect the outcome of the rotator cuff repair. However, active abduction was impaired after trauma, good results were expected.
Background: There are many reports of short term good results of Arthroscopic Subacromial Decompression(ASD), but few long term results have been published. Recently, arthroscopic rotator cuff repair (ARCR) has been addressed as a useful procedure for partial-thickness rotator cuff tear (PRCT). The aim of this study was to investigate clinical results of arthroscopic subacromial decompression(ASD) for bursal side partial-thickness rotator cuff tear(PTRCT). Methods: Thirty three shoulders of 31 patients were included in this study (Ellman's grade I b; 20 shoulders, grade II b; 10 shoulders, grade III b; 3 shoulders). Articular side PTRCT, full-thickness RCT, and calcific tendinitis were excluded from this study. We evaluated clinical outcome according to the Japanese Orthopaedic Assosiation(JOA) score. Results: The average of follow-up term was 24 months (range 6 to 96 months). The average of age at the time of operation was 60 years (range 47 to 76). The average JOA score increased from 68.7 points (range 46 to 85 ) preoperatively to 96.1 points (range 82 to 100) postoperatively. One patient(3.0%)required rotator cuff repair. Discussion: The good result was obtained by surgical debridement and conformity of the 2nd shoulder joint. Postoperative MRI showed a satisfying result except for one case which was required rotator cuff repair. It seems that ASD is a simple and less invasive surgery, and it is one of the optional procedures for bursal side partial-thickness rotator cuff tear which has resisted conservative treatment. Moreover, ASD was usually performed for ARCR, thus it was suggested that it is important to treat the conformity of the 2nd shoulder joint.
Background: The purpose of this study was to evaluate short term clinical results of arthroscopic rotator cuff repair with JuggerKnotTM soft anchors for rotator cuff tears. Methods: We evaluated 28 shoulders in 28 consecutive patients who had arthroscopic rotator cuff repair with JuggerKnotTM soft anchors with a minimum of six months follow up. Average age at the surgery was 60.5 years. 28 shoulders were divided into 4 groups: 6 partial tears, 4 small size tears, 10 medium size tears and 8 large or massive size tears. Clinical evaluation was composed of intra-operative trouble of JuggerKnotTM soft anchor and repaired rotator cuff condition, number of used anchors, active ROM in flexion and abduction; clinical assessment with the JOA shoulder scoring system at 3 and 6 months follow up. Results: Intra-operative JuggerKnotTM soft anchor failure was observed only in one case with a medium size tear and repaired rotator cuff condition was good in arthroscopic findings in all cases. In partial and small size tear, 3.2 JuggerKnotTM soft anchors were used on average. In medium and large or massive size tear, 3.6 JuggerKnotTM soft anchors were used on average combined with 1.6 conventional metal anchors. Preoperative active ROM in flexion and abduction significantly improved postoperatively. Average preoperative JOA score was significantly increased at 3 and 6 months follow up. Conclusion: JuggerKnotTM soft suture anchors were useful instruments in partial and small size tears; they were also useful if combined with conventional anchors in medium and large or massive size tears.
Background: The purpose of this study was to compare the outcome of overhead sports athletes with severe articular-side partial rotator cuff tear between after arthroscopic rotator cuff repair and after arthroscopic debridement. Methods: Fourteen overhead athletes whose dominant shoulders underwent arthroscopic surgery due to the severe articular-side partial rotator cuff tear of the supraspinatus tendon were included in this study. They were followed up for a minimum of one year. Five shoulders underwent arthroscopic repair including 4 trans-tendon repair and one which was repair after the completion of partial tear using double raw technique, and 9 shoulders underwent arthroscopic debridement. Their mean age was 25.4 years old in repair group and 27.2 in debridement group. The ability of overhead sports, the period for return, and the factors for insufficient return were investigated. Results: One athlete completely returned, 2 incompletely returned to sports, and 2 could not return in repair group, and there were 6, 3, and 0, respectively in debridement group. The average period for return was 9.7 months in repair group and 7.8 months in debridement group. In repair group, their cuffs were not completely repaired in all 4 athletes of incomplete return, and residual pain at sports activity were recognized in 3 shoulders after arthroscopic release of postoperative contracture. In debridement group, residual postoperative pain was recognized in 3 shoulders. Conclusion: While it was difficult to completely return to overhead sports after arthroscopic rotator cuff repair, it was possible to return completely and earlier after arthroscopic debridement.
Background: The purpose of the present study was to evaluate the clinical results of conservative treatment for rotator cuff tears. Methods: 33 shoulders of 28 patients were evaluated and diagnosed as having rotator cuff tear with magnetic resonance image or ultrasonography in our institution. There were 13 male cases (17 shoulders), and 15 female cases (16 shoulders). The average age of the 33 shoulders at the time of the diagnosis was 70.9 years old (range 56 to 82 years) and their mean follow-up period was 37.5 months (range 12 to 106 months). With respect to tear size, 4 shoulders were categorized as massive tears, 5 were large tears, 14 were medium tears, 9 were small tears. There was 1 partial tear at the bursal side. The clinical results were evaluated by Japanese Orthopaedic Association shoulder scoring system (JOA score) and pre and post therapeutic active range of motion was also investigated. Results: The average JOA score improved from 69.2 points at first exam to 84.0 points at the final follow-up. However, younger patients (less than 60 years old) showed deterioration. Improvement of active range of motion has been confirmed from 139 to 156 degrees in elevation, from 135 to 150 degrees in abduction, from 57 to 63 degrees in external rotation and from L2 to L1 level in internal rotation at the final follow up. Conclusion: In most of the cases, clinical results of conservative treatment for rotator cuff tears were satisfactory except for younger and active patients.