NINETEENTH ANNUAL MEETING OF THEJAPAN SHOULDER SOCIETY

October 2-3, 1992Iwaki City, Fukushima Prefecture, Japan

President:Shiro Tabata, MD

1. Shoulder Elbow Surg.Volume 2, Number 7, Part 2

A FCllOl-lP STlI>Y IF TIE ACR(JIIOCLAVIClLAR DISLOCA­TION. Akihiko Yonekura, &Nobuyuki Ito,MD, Dept of Or­thopaedic Surgery Nagasaki Univ. Sch. of Med.

Forty-nine joints with traumatic acromioclavicular(A-C) dislocation were reviewed to study the influen­tial factors for their long term results.

Forty-nine joints of 44 males and 2 females werefollowed-up for an average period of 6 years and 9months. The average age at the time of injury was 33years and the types of injury were consisted of type 2(26 joints) and type 3(23 joints) according to Tossy'sclassification. The causes of the injuries were traf­fic accidents infl icted by other (8 joints). industri­al accidents (4 joints) and the others such as sportinjuries (37 joints). Thirty-nine joints were treatedwithin a week after the injury and the other 10 weretreated one month or more, after the injury. The meth­ods of treatment were conservatively (16 joints), thepercutaneous fixation by Kirschner wires (15 joints)and the reconstruction of the A-C ligament (17 joints).

The results of each joint were evaluated clinicallyand radiologically by both the criterias of JapaneseOrthopaedic Association and Kawabe's scores. The re­sults were ca.pared and analyzed considering the age,the type of dislocation, the method of treatment, thecause of injury and the tine of the initial treatment,

In this series, the methods of treatment, the typeof dislocation and the delays in the initial treatmentwere insignificant. However in injuries in which pa­tients had personal benefits such as traffic accidentinflicted by other or the industrial accident hadpoorer results than other cases such as sport injuries.Considering the age factor, older patients had poorerresul ts.

Abstracts 533

3 REGENERATION OF THE RESECTED PART OF THECIAVICLE CAUSING PAIN AFTER WEAVER'SOPERATION A. Sawamoto, MD, & F. Kato, MD,Dept. of Ortho. surg., Tokyo MetropolitanPolice Hospital,

Three cases of bone regeneration at theresected site of the clavicle causing painafter Weaver's operation are presented. Thecause of pain was studied and a modificationof the operative technique is proposed.

Weaver's operation was performed on 10patients with old dislocations of theacromioclavicular joint because continuedacromioclavicular joint pain.

Postoperatively the regeneration of thebone at the resected part of the clavicle wasfound to be the cause of pain in 3 patients.One of the patients required reresection ofthe regenerated bone because of persistentpain. Spontaneous relief was acquired in theremaining 2 patients.

After experiencing these cases theoperative technique was modified to removingthe periosteum when resecting the clavicle.

Bone regeneration has not been observed inthe follow-up study.

Bone regeneration seemed to be the causeof pain after Weaver's operation, wetherefore recommend resecting the periosteumtogether with the clavicular end.

2 ASSESSMENT OF SURGICAL TREATMENTS FOR COMPLETEDISLOCATION OF ACROMIOCLAVICULAR JOINT. Y.Yukawa. K. Watanabe & S. Urata. Dept of Or­thopaedic Surgery, Anjo Kosei Hospital, AnjoAichi Japan

Purpose: There are various ways of treating com­plete dislocation of the acromioclavicular joint,both conservative and surgical. We have had ex­perience with both the Dewar's method and trans­ference of the coracoacromial ligament with bonyfragment of acromion (the modified Cadenat'smethod). In this study we evaluated postopera­tive outcome of both methods.Methods: We used Kawabe's score to evaluate sur­

gical results in 9 patients by the Dewar's proce­dure and 14 patients by the modified Cadenat' smethod, followed up 6 months or more, who couldbe examined in person or interviewed bytelephone.Results: When the Dewar's method had been used,

the outcome was excellent in 6 patients, good in3 and the average score was 91.4 whereas theresult was excellent in 13. good in I, and theaverage score was 96.1 with the modifiedCadenat's method. The mean follow-up period was10 years 9 months and 2 years 6 months, respec­tively. All of the patients have returned totheir current jobs, and no patients have been noproblems in terms of ADL.Conclusion: Both from the ease of surgical tech­

nique and postoperative outcome, the modifiedCadenat's procedure appears to be the more recom­mendable of the two.

4 SURGICAL TREATMENT FOR FRACTURES OF THEDISTAL CLAVICLE. Y.Nakagawa,MD,S.Umegaki,MD,&J. Ozaki ,MD. Dept of Orthopaedic Surgery,Haibara General Hospital & Nara PrefecturalHospital, Nara,Japan.

The purpose of this report is to decide themost reasonable surgical treatment forfractures of the distal clavicle. This studywas composed of 31 patients with the unstablefractures of the distal clavicle. Theiraveraged age was 42.3. All the patients weredivided into 4 types of rentogenogram. Type 1:coracoclavicular ligaments (C-C lig.) are tornand distal segment is not comminuted. Type2:C-C lig. are torn and distal segment iscomminuted. Type 3:C-C lig. are intact anddistal segment is not comminuted. Type 4:C-Clig. are intact and distal segment iscomminuted. Union was obtained in 30 of 31cases. On the basis of our results, werecommend that type 1 with large distalsegment should be treated by tension bandfixation not accompanied with acromio­clavicular fixation, type 1 with small distalsegment and type 2 should be treated bytension band fixation accomanied with acromio­clavicular fixation, type 3 should be treatedby steel wiring fixation, type 4 should betreated by both tension band fixation andsteel wiring fixation.

534 Abstracts

5 HABITUAL POSTERIOR SUBLUXATION OF THESHOULDER JOINT -A CASE REPORT-M. Kamihira, MD, T.Kutsuma, MD, Dept. of Orthop.Surg., Kofu City Hospital, Kofu City, Japan.

We experienced a rare case of habitual posteriorsubluxation of the shoulder joint.

A seventeen years old man. He suffered from thefirst posterior subluxation of the right shoulder jointat 14 years old without trauma. When he elevatedthe shoulder 9O-degrees in neutral position, and thenrotated internally, the shoulder subluxated posteriorly,and when he rotated the shoulder externally, theshoulder was reducted. In the plain roentogenogram(axial view), the humeral head subluxated posteriorly.Moreover, the humeral head subluxated inferiorly

and laterally in the A-P view (Zero position). In CTarthrogram, the hypoplasia of the postero-inferiormargin of the glenoid and the laxity of posteriorcapsule were seen. We performed posterior glenoplasty(Scott) and inferior capsular shift (posterior approach,Neer) for this case. One year and 3 months afterthe operation, no posterior subluxation of the shoulderwas observed. He could return to be a rugby player.Postoperative evaluation using J.O.A. score was 97

points and exellent.The hypoplasia of the postero-inferior margin of

the glenoid and the laxity of posterior capsule arethought to be a cause of the habitual posteriorsubluxation of the shoulder joint. We considered thatwe should perform both posterior glenoplasty (Scott)and posterior inferior capsular shift (Neer) for thisdisease. It is thought that repetitive throwing motionmay occur the habitual posterior subluxation.

6 Old Unreduced Posteriorly DisplacedFracture of the Greater Tuberosity of the

Humerus.- A report of 3 Cases ­

byH. Kawamura, N. Niiro

Dept. of Orthop. Surg., Toya Kyokai Hosp.M. Aoki

Dept. of Orthop. Surg., Sapporo Medical College

We reported three cases that had an old unreducedfracture of the greater tuberosity. The cases showedpathological conditions of both posterior displacement ofthe fragment and rotator interval cuff tear. The formerproduced impingement between the humeral head and theacromion and this made external rotation of the shouiderimpossible on the 90 degrees abduction position. Thelatter showed in sufficiency of the rotator cuff and thismade weakness of the shoulder elevation.The cases were a 63 year-old man, a 54 year-old man

and a 20 year-old man. All of them were treated byostersynthesis and rotator cuff repair. The results ofthese patients were acceptable.

J. Shoulder Elbow Surg.January/February 7993

7 FRESH RUPTURE OF SUBSCAPULARIS TENDON. H. Shinno,MD,T.Fukushiaa MD,&J.Kanematsu MD, Dept of Orthopaed­ic Surgery,Ehime Prefectural Iyomisima Hospital,E­hiae, Japan.

We report a rare case of fresh rupture of the te­ndon of the subscapularis .uscle.

On April 19, 1992, a healthy 50-year-old aan slipp­ed aoo fell while his rildJt hand kept a good graspof a fixture. His right sfioulder was forced into a­bduction and external rotation,and he noted illCdi­ate pain along the anterior aspect of the shoulde­r.

On physical exa-ination, tenderness and swellingwere recognized along the anterior aspect of theshoulder. Active shoulder .cvement was severely li­.ited. Arthrogra- showed extravasion of dye intothe subacrOlial bursae and subcoracoid burusae. C­TA and MRI showed retraction of the subscapularistendon. An operation was performed on April, 24,19­92, the subscapularis tendon was found to be ruptu­red fre. the lesser tuberosity and retracted aedi­allr.The long head of biceps was intact. The subsc­apu aris tendon was repaired to the anterior PQrt­ion of the lrsser tuberosity by a method si.illarto McLauglin s.The rotator Interval was repaired.The post operative course was satisfactory.

The subscapularis tendon is a part of anterior c­apsular aechanis. and its defect causes an increa­se in the instability of the joint. As a result ofneglecting the rupture of the subsc~ularis tendo­n, shoulder pain, loss of strength of internal rot­ation and increased range of external rotation st­ill existed.So the rupture of the subscapularis tendon .ust

be consider the operative treataent.

8 THREE CASES OF SUBACROMIAL BURSITIS WITH FREEBODIES DUE TO RHEUMATOID ARTHRITIS.A.Yoshida,MD,K.Ogawa,MD,M.Takahashi,MD,&T.Matsumoto,MD,'Dept of Orthop.Surg.,Sch.of Med.,Keio Univ.,·Tokyo,Japan.

Three cases of subacromial bursitis withnumerous free bodies are reported. They were 52,62 and 64 y.o.women with long-standing RA,whosecomplaints were marked swelling and pain onmotion in the left shoulders.No significantchanges in the glenohumeral joint were observedradiographically. Each patient had recurrentepisodes of locking,but range of motion wasalmost normal.Subacromial bursogram showedbursal enlargement with nodular filling defects.Because of persistent swelling and pain,thethickened and enlarged bursae together with 90to 155 free bodies ranging from 3 to 25mm insize were surgically removed.No macroscopiclesion was found in the rotator cuffs.Histolo­gicallY,the synovial tissue of the bursaeshowed chronic inflammation compatible with RAand the free bodies were similar to so-calledrice bOd~es observed in chronic bursitis.Afterthe surgeries,the pain and swelling were disap­peared,and not have recurred in all cases.It issuspected that the subacromial impingement dueto thickened bursa initially promoted the syno­vitis and formation of free bodies.A viciouscycle might then develop with the secondary im­pingement between bursal walls and free bodies.

1. Shoulder Elbow Surg.Volume 2, Number 7, Part 2

9 ASEPTIC NECROSIS OF THE HUMERAL HEAD CAUSEDBY DECOMPRESSION SICKNESS.I.Oda,MD,I.Yamamoto,MD,&: H.Kato,MD,Dept of Or:thoDaedic SurjeryKushiro Rousai Hospital 'There has been few reports of asep~ic necro­

sis of the humeral head (ANHH).We present clin­ical and radiological evaluation of ANHH.

Eight shoulders of five patients with ANHHcaused by decompression sickness were reviewed.The age of five patients averaged 48 years,witha range of 27 to 60 years.AII were male divers.The duration of diving experience ranged from20 to 35 years.The range of motion of theshoulders, degree of pain,and disturbance of dai­ly living were evaluated with JOA scoring sys­tem.The roentogenograms (A-P view) of all shoul­ders were observed and classified.

JOA score ranged :from 48 to 98 points,with anaverage of 78.Most patients had moderate pain.The disturbance in daily living and that ofrange of motion were not sever.On the roent'­genograms , spherical segmental opacity of thehumeral head without changes of the joint sur­face (early stage) was found in four shoulders.Sequestration of cortex (advanced stage) wasfound in one. Osteoarthritic change (end stage)was found in three. There was no relationshipbetween radiological stage and JOA score.

o ROTATOR CUFF TEAR ASOCCIATED WITH OS OCROMIALE. AREPORT OF SIX CASES. M.Osaki. & M.Kondo. MD, Dept ofOrthop. Surg. Isahaya General Hosp. N.lto,MD, M. Eto. MD,K. Iwasaki. MD, & Y.Narabayashi. Dept of Orthop. Surg.Nagasaki Univ. Sch. of Med.

When one or more ossification centers of theacromion fail to unite with the body of the scapula isknown as Os acromiale. We report the six casesof rotater cuff tear and discuss the relationshipbetween the occurence of cuff tear and os acromiale.

All patients visited our hospital due to shoulderpain with restricton of motion. Two of them hadno episode of trauma. The diagnosis of cuff tear wasconfirmed by arthrography and Roentogenograms showedosteophyte formation on the undersurface of acromion.Four of them were treated surgically. On exploration,in three cases free movements of os acromiale wererecognized and os acrominales corresponded the tearsite, in other pat ient there was no movement butsubscapularis tendon was torn. Os acromiales wereremoved and the torn cuffs were repaired. and they havegood reslilts. Two patients are treated conservativelydue to less severity of pain. Three patients wereconsidered that the movement of os acromiale andosteophyte formation played the roles of pathogenesisof the cuff tear. But in the case of subscapularistendon tear, may be other cause concerne inpathorogenes is.

In the treatment of every case with os acromialeradical excision or partial excision with fixation ofos acromiale is necessary.

Abstracts 535

11 ARTHROSCOPIC SURGERY FOR FULL THICKNESSTEARS OF THE ROTATOR CUFFT. Kotake,MD, K. Kataoka,MD, T. Mihara,MD,R. Tarumoto,MD. Department of OrthopaedicSurgery, Takashima General Hospital

The purpose of this study is to evaluate theresults of arthroscopic surgery for patientswith full thickness tears of the rotator cuff.

The arthroscopic surgery was composed ofdebridement of rotator cuff, synovectomy andlavage of subacromial bursa and glenohumeraljoint, resection of coraco-acromial ligamentand labral tear, acromioplasty and debridementof glenohumeral joint. our indication for thearthroscopic surgery is the patient who is over65 years old, whose forward flextion could berelieved by injection into the subacromialspace with XYlocaine and who has pain thatdoes not improve with conservative therapy forlonger than 6 months. We have operated 8shoulders with full-thickness rotator cuff tearsand investigated 6 shoulders with a minimum of9 months followup, patient was 3 females and 3men, with age ranging from 65 to 76.

The average score at the followup time was91.6 and gained 31.2 from pre-op value. (JOAScore) The pain relief was improved signifi­cantly. The arthroscopic surgery with thedebridement of the glenohumeral joint was per­formed two of 8 cases. The result of thesurgery without it.

The patient with full-thickness rotator cufftear, who is over 65 years olds and haveintact forward flextion, can be obtained goodresults with arthroscopic surgery.

12 LATISSIMUS DORSI AND TERES MAJOR TRANSFERFOR THE TREATMENT OF MASSIVE ROTATOR CUFFTEAR. T.Takahashi,MD,M.Aoki,MD,T.Ogino,MD,&S.lshii,MD,Dept of Orthopedic Surgery,Sapporo MedicalCollege,Sapporo.

We have performed the latissimus dorsi(LD) and teresmajor (TMa) transfer described by Gerber (1988) for thetreatment of irrepairable massive rotator cuff tears. Wereport the short term results.

[Materials and Methods] Since January 1991 ,eightcases have been treated by this method.Our series areconsist of 7 males and female with an average age of63.6 years (range 48 to 72 years). Follow-up is from 3.5to 21 months (average 10.5 months). These cases wereevaluated by JOA shoulder score .

[Results] Pain was improved in all cases.The averageactive flexion was 117.5· (range 75· to 170· )preoperatively and 132.5· (range SO· to 180· )postoperatively. JOA shoulder score averaged 66.3 pointspreoperatively and 77.6 points postoperatively.Syntheticresults shows that excellent is obtained in three cases,good in one,fair in one,and poor in three cases.

[Conclusion] The transfer of LD and TMa relives painand aids recovery of function.

536 Abstracts

13 TWO CASES OF ROTATOR CUFF TEARWITH SUBACROMIAL SPURMasaru Nanba, Norikazu IchikawaDepartment of Orthopedic Surgery, Kochiprefectural Aki Hospital

Various causative factors in rotator cufftear have been suggested by many inves­tigators' and acrominal spur may be one ofsuch factors. In this report, 2 cases ofrotator cuff tear with subacromial spur aredescribed.

In both patients reported here, the spurwere ossified ligaments extending anteriorlyand downward from the insertion of thecorawacromial ligament. The rotator cuffwa:, completely teared in both cases. Thespur was considered to be the direct causeof its tear in Case 1, because the super­ficial layer of the cuff was markedlyabraded in a crater-like shape. In Case 2,on the other hand, the tear was already soextensive that its cause was difficult to bedetermined.

14 ISOKINETIC MUSCLE STRENGTII AFTER REPAIR OFPARTIAL TEAR OF TIlE ROTATOR CUFF BY FASCIAL PATCHIlETHOD H. Sano, MD, £ S. Tabata, MD, Dept ofOrthopedic Surgery, Iwaki Kyori tsu GeneralHospi tal, Iwaki, Japan.

We evaluated the postoperative isokineticmuscle strength of patients wi th partial tear ofthe rotator cuff who had undergone repair ei therby McLaughl in's method or by the fascial patchEthod. The IIUscle strength after the fascialpatch is generally considered to be inferior tothat after McLaughlin's IIethod.

Seven shoulders of 7 patients who underwentrepair by the patch Jllethod were evaluated. Theiraverage age was 56. 7 years (range 38 -67). Nineshoulders of 9 patients who underwent repair byMcLaughlin's method were evaluated. Their averageage was 41.6 years (range. 17 -64). The meanpostoperative period was 2.9 years in the patchgroup, and 1. 8 years in the McLaughl in group.

1) 60 deg./sec. The average peak torque of theinvolved shoulder was 89.8 % of that of thecontralateral shoulder in the patch group and 100.9% in the McLaughl in group.

2) 180 deg. / sec. The average peak torque was 97.4 % in the patch group, and 96.3 % in theMcLaughlin group.

Postoperat ive recovery of IIUSC1e strengthafter fascial patch repair was similar to thatafter IIcLaughl in's method.

J. Shoulder Elbow Surg.January / February 1993

15 TWO TECHNIQUES FOR OBTAINING THE EFFECfIVE

EARLY LARGE RANGE OF MOTION OF THE SHOULDER.

Dept. of Orthop. Surg., Sch. of Med., Fukuoka Univ. Teroaki

Izaki, Yozo Shibata, Koji Midorikawa, Kosuke Ogata, Takao

Iwasaki, *Masafumi Hara, **Mitsuru Takeshita, ***NahotoTakagishi.

*Hisatsune Hosp.,**Sawara.Orthop.,Hosp.,***Minamikawa

Orthop. HospitalMter operation of the shoulder, it is of importance to get large

range of motion (ROM) and to relieve of pain. In order to

achieve these objectives effectively, it is important to start

passive ROM exercise as soon as possible after the

operation.Since 1989, we adopted two techniques for obtaining

the effective rehabilitation. l.To prevent voluntary contraction

during the passive ROM exercise, relaxation exercise was

performed preoperatively. 2. TO minimize a damage to the

deltoid muscle, and to preserve the continuity of the muscle fiberbetween the trapezius muscle and the deltoid muscle, these

muscles were lysed under the periostium of the acromion. As a

result, we can start passive ROM exercise from 1st day after the

operation. It was effective to gain ROM of internal rotation that

need "Making knot in back" or "Self hygiene care".

16 THE FUNCTIONAL DIAGNOSIS OF THE SHOULDERDISORDERS USING THE ORIGINATED ROENTGENOGRA­PHICAL TECHNIQUE NAMED ·SCAPULA-45-. H. Tsutsui.MD, R. Yamamoto,MD, LAnraku,MD, K. Mihara, S. Hokari.K. Suzuki, H. Uezato, T. Uch ikawa, & M Yamaguchi, PT, Deptof Orthopaedic Surgery, Showa Univ. FujigaokaHospital,Yokohama, Japan.

Our originated roentgenographical technique named"Scapula-45- could estimate the function of gleno­humeral and scapulothoracic joints. We took X-rayfilms in the four different conditions which are O°and45° elevation in the scapula plane with/wi thout 3 kgweight loading. We could investigate the functionaldiagnosis of the joints by the four X-ray films.Based on the result of normal volunteers' X-ray films,X-ray films of each cases who had shoulder problemswere analysed their characteristics. The cuff indexwas suggested the relative cuff function and coulddecide the capacity of the cuff function which wasconti rmed by e Iec tromyography. The increased cuffindex in the 45° elevation was showed in 76.6% cases.

The activity of their supraspinatus and/or infra­spir~lu.; muscle was relatively decreased. Thescapulaind,;x also suggested the function of scapula. 32%cas"s showed the stiff scapula. Decreased scapulaindt' x fro;'1 0° to 45° elevation showed pain on motionand/or impingement in the lower elevated level. Inconc!usioro. our originated X-ray technique named·Scapuia-45"could make the functional diagnosis whichlead to select the adequate treatment.

KEY WORDSShoulder joint. Roentgenography. Diagnosis

J. Shoulder Elbow Surg.Volume 2, Number 7, Part 2

17 THE RANGE OF ROTATION OF THE SHOULDER IN THEVARIOUS POSITIONS OF THE ARM. K. Mimori, TokyoMedical and Dental University.

The range of rotation of the shoulderchanges with the three dimensional position ofthe arm. We measured the range of rotation inthe various positions of the arm. A magneticsensor system (3 SPACE TRACKER SYSTEM fromMcDonnel-Douglas Corp.) was used to measurethe rotation of the shoulder. 1) Subjects were10 males. 2) Six glenohumeral joints of thecadavers were used. The rotator cuff was cut,while the capsule was reserved. The range ofrotation of the shoulder in normal subjectswas largest at 30° elevation and 30° posteriorto the frontal plane, while in the cadavers at30° elevation in the scapular plane.

18 OOATIrn BE'M:EN ElEVATIrn AND ImATIrn CF 'DIE SIDJUER.T. Nakagawa, MD, Tokyo Medical and Dental University.

The rotational IIDtion pattern accanpanying the elevationin varioos planes ~ investigated in normal subjects andcadavers. To measure the IIDtion of the shoulder, amgnetic sensor system (3 SPACE lllACKER SYSTEM fremMcfunnell-Ihtglas OJrp.) ~ used. Using this device, thethree dimensional relative angle of the arm (ht1Derus) tothe trunk (scaplia) ~ measured. Starting position~ anatural dropping position and defined as 0° rotation.

1) &1bjects were bienty males with normal shoulders.They elevated their arms in 12 vertical planes atintervals of 150. Little rotational IIDtion occurred duringthe elevations in 60° and 75° anterior to the frontalplane. External rotation occurred during abduction, andinternal rotation occurred during flexion. In the scap.tlarplane elevation (30° anterior to the frontal plane), themean agnle of rotation at the maxiJIun elevation~ 49°external rotation.

2) Six glenolumeral joints of cadavers lOere used. Therotator cuff ~ cut at the site of the insertion and thecapsule ~ retained. The scap.tla~ fixed on a plate.The hunerus ~ elevated by the investigator's finge in 9planes at intervals of 15°. The position of the hUDerus atmaxiJIun elevation~ on the average 34° anterior to thescap.tlar piane. In the scap.tlar plane elevation, the meanangle of rotation at the maxiJIun elevation~ 51 °external rotation.

Abstracts 537

19 Isokinetic evaluation of shoulder rotationalstrength during concentric and eccentricaction. K Suzuki,MO,A Minami,MO,MTakahara,MO,N Suenaga,MO,H Suzuki,PI', Deptof Orthop Surg,SChool of Med. Div of Phys'!her ,Hokkaido Univ . ,sapporo.[Puropose] In order to quantitatively definerequirement of adequate protective synergyof the internal and external rotators, weevaluated isokinetic strength duringconcentric and eccentric activity, in nonnalshoulders and patients with anteriorinstability. [Materials &Methods] 15asymptanatic volunteers, 12 patients withanterior instability were evaluated in thisstudy. Isokinetic strength was measured ina standing position, with shoulder abduction45°, flexion 30°. [Results] 1) No patientshad .:moulder pain and apprehension duringmeasurement. 2) Eccentric am concentricactivity rations were about 1.2, lower thanother muscles. In patients with anteriorinstability, those ratios of .internal rotatorswere hi~her than nonnal shoulders. 3) Inpatients, not only internal rotators butexternal rotators decreased during concentricand eccentric activity. (Conclusion] '!hesefindings are useful when planing the preand post-operative exercise of patients withanterior shoulder instability.

20 UNTREATED RESULTS OF THE ATRAUMATIC SHOULDER IN-STAB I LI TY. S. Kuroda. 110.• T. SumiyoshL MD.. M. SaL MD.&J. Jloriishi.IID. lIatsudo Orthopaedic Hospital

Untreated and over-one-year results in 268atraumatic shoulder instabilities were inves­tigated. The mean age was 20.1 years old. Ilalepatients were 103 shoulders and female were 165shoulders. The mean follow-up period was 33. 1months. 196 shoulders were loose shouldersyndrome. Forty shoulders were voluntary disloca­tion. Thirty-two shoulders were positional in­stability. Various disorder changes between looseshoulder syndrome. voluntary dislocation and posi­tional instability were recognized in 23shoulders(8.5%). Spontaneous recovery was recog­nized in 24 shoulders. The incidence of spon­taneous recovery was 12. 6% in male patients and6.6% in female. It was 2. l' in the adults and12.5% in the adolescence. The mean recovery agewas 16.8 ranging from 13 to 23 years old. Thereal incidence of spontaneous recovery is supposedto be more than this research. The incidence ofatraumatic shoulder instability is different ineach age group. By using the dispari ty in the in­cidence of atraumatic shoulder instability of eachage group the practical incidence of spontaneousrecovery can be estimated. The incidence of spon­taneous recovery in patients whose age is 14 to 16years old is supposed to be 19.7% in three yearsfrom now and 35. 8% in 6 years.

538 Abstracts

21 STRENGTHENING EXERCISE OF ROTATORMUSCLES IN SHOULDER INSTABILITYM. Tanaka, MD; T. Nakagawa, MD' M. Tsuchiya,MD, Dept of Orthopaedic Surgery, tokyo Medicaland Dental Unlv.

The surgical treatment has been conyentionl!lllypaid attention for therapy of shoulder Instability.However, it is considered that not only surgicaltreatment, but also effectiveness and limitation ofthe conservative therapy should be studied takingpossibility of the natural healing and complexityof the pathology into consideration. We carriedout strengthening exercise of rotator muscles inshoulder instability.

Twenty joints in 10 patients with inferiorinstability of the shoulder who were chieflycomplained shoulder disturbance.

The isometric exercise of rotator muscles whichwas proposed by Dr. Neer; was mainly carried outfor 8 weeks, and physical rinding, stress X-p andmuscular power were evaluated at the starting andfinishing periods after 8weeks.

The increasing rate of muscular power wassignificantly larger in the external rotators thanthat in the Internal rotators. The improvement ofsymptoms was observed in all 15joints withshoulder disorder. The descending rate of thehumeral head by stress X-p was improved in 120f15joints in which were recognized the increase ofthe muscular power more than 100,,{, in the internalor external rotators.

We consider that improvement of symptom~ andstability can obtained by strengthening exercise ofrotator muscles in shoulder instability.

22 THE RESULTS OF SURGICAL TREATMENT OF NON-TRAUMATIC INSTABILITY OF THE SHOULDER. T.Kobayashi, MD, E. Shimozaki MD, PhD, H. Itokawa MD, K.Kitaoka MD, T. Matsumoto MD, PhD, & K. Tomita MD, PhD:Dept of Orthop. Surg., Sch. of Med., Kanazawa Univ., Japan.

For non·traumatic instability of the shoulder, we haveperformed inferior capsular shift (ICS) according to the maindirection of instability and added glenoid osteotomy (GO) fordysplasia or retroversion of the glenoid. The purpose of thisstudy is to evaluate the results of our operative intervention.We evaluated 16 shoulders (14 cases), 5 of which were maleand 11 female, three shoulders were habitual subluxation(HA) and 13 shoulders inferior and multidirectional instability(I&MDI). Average age at operation was 16.1 years and theaverage follow-up period was 31.4 months. ICS (ant.approach) was performed for 9 shoulders, ICS (post.approach) for 2 shoulders, GO and ICS (post. approach) for 4shoulders, and GO and ICS (simultaneous ant. and post.approach) for 1 shoulder.The results for 3 shoulders with HSand 9 shoulders with I&MDI, which was mainly 2-directionalwem geod. However the results for 4 shoulders, which hadse"ere three-directional instability, were less favorable exceptfor 1 shoulder for which a simultaneous anterior and posteriorapproach was used. Either the anterior or posterior approachis roughly adequate for one or two directional instability. Thedegree of instability in three-directional instability is severerthan that in one or two directional. Stabilization using asimultaneous anterior and posterior approach for severethree directional instability might be more preferable than thatusing either anterior or posterior approach , because ofresidual symptom.

J. Shoulder Elbow Surg.January / February 7993

23 GLENO-TILTING ANGLE AND HUMERALRETROTORSION ANGLE IN RECURRENT ANTERIORDISLOCATION OF THE SHOULDER. K. Yanaga, Dept .ofOrthop. Surg.,Saiseikai Shigaken Hosp. Siga.(Purpose)

The purpose of this study is to evaluate the relation of thepredisposing osseous factors of recurrent anterior dislocation ofthe shoulder(RAD) using computed tornography(CT), whichmade easy and accurate measurement of gleno-tilting angle(GTA),humeral retrotorsion angle(HRA) and glenohumeralindex(GI).(Materials and Methods)Between 1985 and 1992, fifty-three shoulders in 50 patients

under 40 years old who were diagnosed RAD have beenexamined by CT. Their average age was 21 (range,15-39).Forty-three patients were male and 7 were female. For thecontrol group, 33 shoulders in 21 patients who had noinstability were examined. Using Logitec K-510 digitizer,GTA,HRA and GI were calculated from seven points whichwere mesured at anterior,posterior and medial edges ofscapula, two maxium diameter points of humeral head,medialand lateral epicondyle. Involved side group, uninvolved andcontrol were compared with t-test.(Results)GTA, HRA and GI in involved sides were O.1°±3.2°,

25.3°±11.4°,59.8±6.4, in uninvolved were -o.2°±2.9°,28.1°±12.8°,62.5±6.8, and in normals were 1.3°±4.0°,30.3°±13.2°,61.0±3.9(mean±SD). GTA,HRA,GI were notsignificant between each group.(Conclusions)The authors considers that there are little predisposing

osseous factors in RAD such as anterior glenoid tilt,humeralretrotorsion or malformation of glenoid.

24 cr ARIHID;RAM AND m:GNJSIS OF TRAUMATIC ANIERIORDISLOCATICN OF TIlE SInlLIER. H. Hirose, MD and E.Fujimaki, MD.

Purpose: The present paper deals with the relationshipbetween erA at initial and redislocation basing thediscussion on the results of the follow-up examination.

Methods: The subjects ~re 40 patients with 40 shoulderjoints involved "*to visited our hospital because oftraumatic anterior dislocation of the shoulder and allthese cases were examined by erA at initial. These cases~re followed by personal examination and telerhone todetennine their prognosis.

Results: The prognosis could be determined in 33 of 40patients. The treatment consisted of less than 3 ~eks of:imrobilization (3 patients), m:>re than 3 ~eks of:imrobilization by sling or Desault I s bandage (5 patients),and :imrobilization with our clavicular harness (25patients). The initial dislocation-to-follow-up intervalsranged frem 1 year to 8 years and 3 m:mths (average 4 yrs.6 m:m.). As many as 10 patients (33.3%), all under 25years of age, redislocated. According to Ishikawa'sclassification of erA, type III dislocation recurred at ahigh rate Of 6/8.

Conclusion: Patients "*to are diagnosed by erA as havingtype III or severe traumatic anterior dislocation of theshoulder are at a high risk of recurrence. Dislocations ofthese types deserve treatment by surgical intervention.

J. Shoulder Elbow Surg.Volume 2, Number 7, Part 2

25 NATURAL HISTORY OF INTRAARTICULAR LESIONSIN SHOULDERS WITH TRAUMATIC ANTERIORINSTABILITY. N. Tsumaki*, M. Yoneda, A. Hirooka, K.Hayashida, S. Wkitani*, K. Ono*, * Dept of OrthopaedicSurgery, Osaka Univ. Med. Sch., Osaka - JapanPurpose CT arthrography (CTA) can provide precise

quantitative data on intraarticular lesions of the shoulder. Wequantified the intraarticular lesions of patients withdislocating or subluxating shoulders using CTA, andattempted to determine the pattern of progression of theselesions. Methods Forty-eight shoulders in 47 patients withrecurrent dislocation or subluxation on less than 8 occasionswere evaluated by bilateral CTA. Thirty-three patients haddislocation and 14 had subluxaion, and the average age atinjury was 19 years. The width of the attachment of theanterior inferior glenohumeral ligament (AIGHL) to theglenoid rim and the redundancy of this ligament weremeasured by CTA. The length, width, depth, and location ofany Hill-Sachs lesions were also determined. Then thecorrel~tions of these data with the number of dislocations orsubLI"al:ons were analyzed. Results As the number ofdisllCations or subluxations increased, the attachment of theAle HL to the glenoid rim became narrower and the Hill­Sac!.s lesi,'ns became wider. However, there were nosigni,'icant correlations between the number of dislocationsor suhh,'atlons and the degree of redundancy of the AIGHLor tile length, depth, and location of the Hill-Sachs lesions.Conclusions Since a narrow AIGHL attachment to theglenoid 'rim on CTA reflects ligament retraction, it wasconcluded that the AIGHL becomes more retracted as thenumber of dislocations or subluxations increases.Therefore, early surgical treatment is recommended fortraumatic anterior shoulder instability.

26 A CINERADIa.\RI1lID;RAHlIC S1UDY OF TIlE I)AMAGED ANlEID­INFERIOR GlEIDID ELGE. Y. Rata and K. Nobuhara, NobuharaHospital.

Three thousand and foor hundred patients ~ ccmplainedof shoulder pain underwent cineradioarthrography fran 1982to 1992. Of those patients, one hundred and eighty-twoshoulders became the subjects to reveal the degree ofdamaged anteroinferior glenoid edge (=IW::E).

The size of the IW::E was measured using the PIAS IA-500system. A ccmparative analysis of the horizontal and thevertical lengths of the area was made.

Of the one hundred and eighty-two shoulders with IW::E,one hundred and thirty-two had recurrent dislocation(ROO), twenty-one with Rotator Interval lesion, eighteenwith recurrent subluxation, seven with instability, sevenwith rotator cuff tear, and one with primary dislocation.The mean size of the IW::E in unstable shoulders is SIII!lllerthan the rest (p 0.05). The horizontal length of the IW::Ewas longer than its vertical one significantly (p 0.01). Acorrelation exists between the area of the IW::E and itshorizontal length (r=O.60), and a closer correlation wasnoted with its vertical length (r=O.71). Of the onehundred and twenty-eight shoulders operated for RDS, thesize of the IW::E differ between those with and withoutanterior capsular elongation (p 0.01). No difference wasobserved regardless of the runber of dislocations.

Abstracts 539

27 rn TIlE USEFUINESS OF MR ARIlflUjRAPHY IN TRAlJMATIC ANlERIORINSTABILIlY AND DISlOCATIrn OF TIlE S!OJLIER. H. Itokawa,M.D., Kantou Teishin Hospital, Shinagawa--ku, Japan.

Arthroscopic: Bankart procedure has cane to be performedfor the anterior instability of the shoulder recently. Forthe prrpose of grasping pathophysiology before thearthroscopic examination, we performed MR arthrography(hereinafter abbreviated to MRA) and studied itsusefulness in ccmparison with cr arthrogram (hereinafterabbreviated to erA) as to ~ether or not the uphology,qualitative diagnosis and localization of Bankart lesioncan be judged.

MRA and erA were performed for a total of 26 cases ~ich

are broken down to 14 cases of traumatic anteriorinstability of the shoulder and 12 cases of traumaticanterior dislocation of the shoulder (first time).

The llDrphology of labrum was classified according tothe Ishikawa's classification, and with MRA, Zlatkin'sclassification was done to study the IOOrphologicaldiagnosis, qualitative diagnosis and localization of thelabrum. Furtherroore, arthroscopic examination wasperformed in 7 cases.

MRA, though inferior to erA in contrast visualization,is free of exposure to radiation and useful for judgingdegenerated rupture and localization of the labrum.

So MRA can serve as an auxiliary diagnosis beforearthroscopic examination for reduction of Bankart lesionwith surgery under an arthroscope also taken intoconsideration.

28 MR IMAGING OF ANTERIOR LABRUM AND CAPSULAR ATTACHMENTOF THE SHOULDER. M. Horii M. D.• T. Kubo M. D.. M. Kurokawa M. D.•Y. Hirasawa Prof. Dept of Orthopaedic Surgery. KyotoPrefectural University of Medicene.Kyoto. Japan

The anterior glenoid labrum and capsular insertion wereobserved on MR imgages in condition with joint effusionor injected physiolosical saline with special attensionto instability. Forty-seven shoulders of 36 patientswere imaged with T2' weighted sequences. The patterns ofcapslar insertion were divided into 4 major types.Capsule seemed to have some continuity to the labrum intype 1. It inserted more medial to the neck of thescapula in type 2 and to greater extent in type 3. Everycase with· glenoid edge fracture or bony deffectclassified into type F. The assesments were done on theimages of mid"glenoid level and of the most inferiorlevel. On the most inferior level of the glenoid. 22 of25 shoulders with traumatic anterior instability 06dis l;'tion and 9 subluxation) had type 2"4 insertion.There were 11 joints with type 1 insertion out of 18CO~ltrast cases. In cases of subluxation. there were 2 oftype I insertion and 3 with normal labrum. and contralythere were 3 of type 4 insertion and 2 with large bonydefect of glenoid edge. The joints with large cuff tearhad type 2 (2 shoulders) or type 3 insertion with labraldefectU shoulder). The images of mid"glenoid levelconsidered not to be adequet for the assesment because 14shoulders of control group had type 2 or 3 insertion andlabral changes were less typical on the joints withinstability. There seemed to be some relations betweentraumatic anterior instability and types of capsularinsertion but not for every individual cases. Rathersevere inj ury on anterior aspect of the glenoid seemed tomade the reduction easy in some cases diagnosed astraumatic subluxation.

540 Abstracts

29 PATHOLOGICAL ANALYSIS OF PRAD AND PRAS-ISIT POSSIBLE TO DISTINGUISH THESE TWODISORDERS BY SELF-REDUCTION?- K. Maruyama,MD, M. Oguchi, MD, S. Sano, MD*, K. Saito,MD* & Y. Yamaguchi, MD*, Dept of Orthop Surg,Akiru Municipal General Hosp & *Dept ofOrthop surg, Nihon Univ. Sch. of Med.

Subluxation is generally diagnosed if thejoint is reduced by itself. We investigatedthe following points; 1) pathological differ­ences between PRAD and PRAS, 2) possibilityto distinguish these two disorders by "self­reduction". 85 cases 87 joints of PRAD andPRAS were divided into two groups; the groupD which consisted of 59 cases 60 joints diag­nosed PRAD and the group S which consisted of26 cases 27 joints diagnosed PRAS. These twogroups were compared by history of disloca­tion, joint laxity measured by Floating meth­od and arthroscopic findings. Applied forceat their initial dislocation and the grade ofHill-Sachs lesion of group D was thought tobe severer than group S averagely. Jointlaxity was stronger in group S than in groupD. About the half of this series changedmode of recurrence in their past history. Wewould like to conclude that these twodisorders are overlapped each other in theirpathologies and that it is impossible todistinguish them by "self-reduction".

30 INDICATON OF THE MODIFIED BOYTCHEV'S PROCEDUREWITH GLENOID BONE GRAFT Y.Shibata,M.D., K.Midorikawa, T. lzaki, K. Ogata, M. Takeshita, N. TakagishiDept. of Orthop. Surg., Sch. of Mad., Univ. of Fukuoka,Fukuoka, JAPAN(purpose) Modified Boytchev's procedure(MBP) for recurrentshoulder dislocation can repair the pathology of the damage ofinferior gleno-humeralligament and insufficiency ofsubscapular muscle. Attempts to treat the shoulder with largebone defect of glenoid(B.defet) presented difficulties, thoughwe obtained good results by this procedure(re-dislocation rate4%). This study will present the indication of MBP with bonegraft.(method) Sixteen of 100 shoulders that were performed MBPhad B.defct Bone graft to the glenoid rim was performed for 4of 16. The size of B.defet was calculated by comparing withuninvolved side. (results) Only MBP was performed for 11shoulders under 20% of B.defet. Tree of 5 shoulders had 10­20% of B.defet had inferior instability at pre-operative stateand they felt apprehension feeling after surgery. Five of 6under 10% of B.defet didn't complained of apprehensionfeeling and didn't revealed apprehension test. MBP withbone graft was performed for 4 shoulders over 20% of B.defeton the basis of experience that re-dislocation case with 25% ofB.defet. This case re-dislocated one year after first operationwithout relief of apprehension feeling.(conclusion) 1. Under 10% of B.defet: MBP is performedalone. 2. 10-20% of B.defet: bone graft is relative indication.3. Over 20% of B.defct bone graft should be performed withMBP.

J. Shoulder Elbow Surg.January/February 7993

31 lIDDIFIED I3RISIOtI ffiXEllJRET.fl'brioka,MD, ~pt. of Orthop. Surg., Yokdlama lIt.InicipalCitizen's lbspital

I.e have teen able to follow up (over 10 years) 23patients whose ranged in age at operatim fran 16 to44 years. The 16 patients of them \\ere male and 7 patientsfemale. The average of follow up term is 12 years and9 IOCI1.ths.

No dislocatim recurred and pain m IIDtim was experiencedin 2 patients. Mild limitatim of external rotatimwas seen in 11 patients, which was 10 degrees m average.Return to sports was accanplished by 13 patients, 9of whan played their original sport, and 4 enjoyed soreother spor't.

As to the canplicatims, ncn--unim occurred in 1patient with deviatim and breakage of the screw. ~viatim

of the screw was respmsible in 2 and breakage of thescre~y' ill ncne.

irthroois of the shoulder joint was seen in 4 patients,1 'If whan had ncn-unim with deviatim and breakageof the screil, and 2 had deviatim of the screw.

Carvlica';im by nerve paraly",is or vascular injurywas GOOt' ("led in none.

This operatim gives not mly the mechanical ruttressagainst the dislocatim, rut also the nuscular defenseagainst the dislocatim fran the starxlpoint of kinesiology.These advantages assure the good results even in sportarenand heavy laborers.

32 THE UTILITY OF STATAK SOFT TISSUE ATTACH-MENT DEVICE FOR THE BANKART REPAIR.K.Tamai,MD, Y.Sawazaki,MD, I.Hara,MD,M.Minakami ,MD, and D.Osada,MD. Dept ofOrthopaedic Surgery, Dokkyo Univ. Sch. ofMed., Tochigi & Hara Orthopedic Hospital,Tokyo

We report the experience of utilizingSTATAK to attach the capsular extensions tothe glenoid rim during the Bankart proce­dure. Fifteen patients who underwent Ban­kart repair with this device were reviewedand compared to 17 patients operated withthe transosseous suture technique. Theoperati ve time was 18 minutes shorter inaverage with the use of STATAK. It was feltthat this device was particularly effectivein patients with rounded glenoid rim. Thesurgical results were satisfactory in 12cases and unsatisfactory in three. Twopatients whose x-ray revealed improperplacement of the device showed recurrenceof instaQility postoperatively. We concludethat th~ STATAK benefits the surgicaltechnique and the operative time if secure­ly inserted into the bone.

J. Shoulder Elbow Surg.Volume 2, Number 7, Part 2

33 EVALUATION OF ISOKINETIC STRENGTH OF RECURRENTDISLOCATION AND SUBLUXATION OF TilE SIIOULDER. K. Sempo,Dept. of Orthopaedic Surgery, Midorigaoka Hospital,Osaka. II. Kurokawa, MD, II. Terawak i, & Y. II i rasawa, liD. ,Dept. of Orthopaedic Surgery, Kyoto Prefectural Univ.of lied., Kyoto.

The authors evaluated isokinetic strength(IS) ofthe recurrent anterior dislocation and subluxation ofthe shoulder before modified Bristow procedureand fo llowed the change of IS before operation, 3months and 6 months after modified Bristow procedure.

Eight cases of recurrent dislocation and 8 casesof subluxation of the shoulder were examined. lien 16,women 2: average age 20.6 years, ranging from 15 to32. All of their involved side were dominant side.Averagepeak torque per body weight at 90deg/sec andtotal work per body weight at 180deg/sec was measuredwith LIDO active system in flexion(FL), extension(EX),external rotation(ER), and internal rotation(IR).

Average peak torque of dominant side of patientswas statistically less than non-dominant side by 15%in FL,maybe caused by apprehension. Three months afteroperation, average peak torque of involved side wasranging from 55.5% (IR) to 68.4l6 (ER) compared wfthbefore operation, but after 6months, recoverd to 93.9%(FL) and 1l0%(EX)of preoperative state. Total work wasranging from 59.4% (IR) to 90.6% (FL) 3 months afteroperation, but recovered to 88.3% (IR) and 131% (EX),6 months after modified Bristow procedure.

Three months after modified Bristow procedure,recovery of IS was unsatisfactory for athletic sports,but 6 months later, IS was recovered to almostpreoperative state. IS of recurrent dislocation ofshoulder tends to decrease in FL,and so, more trainingwill be necessary for flexor muscles.

34 EVALUATOIN OF THE MUSCLE STRENGTH OFRECURRENT DISLOCATION OF THE SHOULDERAFTER BANKART PROCEDURE K. Hirayama, MD,J. Hashimoto, MD, &K. Mizuno,MD, "Dept of Orthop.Surg. Kobe Univ. Sch. of Mad.,

The purpose of this report is to evaluate the musclestrength of recurrent dislocation of the shoulder afterBankart procedure.(Methods) The shoulder of 26 patients after Bankartprocedure were analysed. The average follow-upinterval was 8.1 months (range 5 to 13 months)postoperatively. lookinetic muscle strength testing wasexamined by using Cybex 2. We measured the peaktorque as a maximum strength and caliculated thepercentage of involved/not-involved side.(Results) The muscle strength of the involved side was83.60/ in flexion, 93.1 % in extension, 78.8% inabduction, 87.1% in adduction, 88.6% in internalrotation, and 73.1% in external rotation. The musclestrength of the involved side was lower in all directions,especially in abduction and external rotation.(Conclusions) The muscle strength plays an importantrole in stability of the shoulder. Therefore. Bankartprocedure is recommended to be perforemed in earlystage of recurrent dislocation of the shoulder to get goodresults regarding postoperative muscle strength.

Abstracts 541

35 Problem of Adson's test for thoracic outlet syndromeThe effect of a deep breathing for Ad son test

Department of Orthopaedic Surgery,Kumamoto University School of Medicine

Toshio Kitamura, Katsumasa Thkagi, Makio Yamaga,Keizou Morisawa, Yasufumi Kataoka

A deep breathing causes a transient decrease of bloodflow in the arms by neum reflex. A deep breathing iscontained in Adson maneuvers, and so we investigated theeffect of a physical decrease of blood flow by a deepbreathing for Adson's test. In 42 TOS subjects and 30 healthyones, reaction time and cardiac waves during a blood decreasewere examined by Laser Doppler Flowmetry on the conditionthat 1. A deep breathing in sitting 2. Ad son test 3. ReverseAd son test. And 10 operative subjects with anomalies ofscalene triangle were examined retrospectively in the samemethod.

Reaction time and cardiac waves during Adson's test andreverse Adson's test were in agreement with these of a deepbreathing in sitting (the rate of the former to the latter is0.957±0115). All subjects had no signs of a continuousdecreasing blood flow and obliteration of cardiac waves.

These findings indicate that Adson's test is greatlyeffected by neum-reflex of a deep breathing, and its test doesnot reflect vessel compression. Accordingly Adson's test is notso useful for vessel compression test.

36 QUANfITATIVE EVALUATION OF BONE MINERAL DENSITYOF THE HUMERUS IN THE PATIENT OF PERIARTHRITIS OF

THE SHOULDER. Keisuke Okamura&J iro Ozaki, MD, Dept ofOrthopaedic Surgery, Saiseikai Nara Hospital, 4-643 Hachizyo-dlo, Nara

63J, ]apan,aud Nara Prefectural Hospital, 1-30-1 Hiramatu-dlo, Nara 630,Japan.

PURPOSE: The Jl.IIlXlBe of this stu:ly was to colle::t infonnatim a1nJ.tostEqleOia in the uwer eo:I of the laImerus flOOl a series of im:liyiciJals suffering

£rem periarthritis of the slDulder. BMD of the greater tubercle of the lmnerus in

the cases of periarthritis of the sOOulder ani in the reference cases was IIlEElSllCed~ UOliIg DEXA(DuaI energy X-ray absorptiometry ).

METHODS: In 18 cases of periarthritis of the sOOuIder, 8 women aud 10 men,

the 1xne mineral deusi ty of the greater tubercle of the humerus was evaheted.

1he average age of the patients was !Xi.5 years in men ani 57.6 y81rs in wcxnen.

In the reference cases, 9 wanen am 9 men. nuxhmly selected perscns ( ager&rge. 24-~) widDut any history of injury or disease in the uwer extremities,

the bne mineral dwsi ty was meu.sured.RESULTS: In the reference cases, the humerus uf hanr:l<Q,ess cmtained more

mineral than did the cmtralatecral ene. All the watlfSl of periarthritis b£ thesOOulder were right huxIed aud all wt me 1aI an affected righe side. Excepting me

case J there was a s igni fieant decrease 0 f b:ne mass in the affected side as

CODI(llnld to that of the _flected. In the cases of men of periarthritis of

the sb:Julder. the lumerus of lJudeiless bad a t~ to CCIltain more mineral

thm did the cootralat~l em. ~,nqe of motim aOO duratim of the disease

could not be demmst,.,jted to influence the degree of osteopeuia.

CONCLUS IONS: UlBMD of the greater tmercle of the humerus was measu­

red ~ usiIg DEXA. (ZlThe degree of ost_ia associated with periarthritis of

the shoulcEr was significant in females. (3) In the refennce cases, the mineral

deosi ty was fowl to he higher in the huxIed side.

542 Abstracts

37 OSTEOPENIA IN THE FROZEN SHOULDER. H.Shibuta,K. Tarnai, H. Katumoto & K. Kosaki, Dep. ofOrthopaedic Surgery, Yokohama Rosai Hospital

The purpose of this study was to clarify thedegree and related factor of bone mineral lossin the proximal humerus in patients with frozenshoulders. The subjects consisted of 10 casesof unilateral shoulder contracture withoutproceding trauma. Average age was 56 years.The mean duration of disability was 5.8 months(2-12 months). Bone mineral content(BMC) wasmeasured through DEXZ using Norland XR 26. The

BMC of frozen shoulder was 83% in the proximalhumerus, 92% in the humeral shaft and 99% indistal end of the radius compared to that of theunaffected side. The BMC was markedly reducedin the proximal humerus. Age, duration of dis­ability, range of flexion was not correlated withosteopenia in the proximal humerus. Two shoul­ders with 2 months'history showed significantosteopeQia. The impairmen~ of external rotationand external rotation ratio compaired to the un­affected side was slightly correlated with lossof BMC in the proximal humerus. In conclusion,frozen shoulder was associated with significantosteopenia in the proximal humerus. This seemedto appear in early phase of the disease. Theimpairment of external 'rotation was slightlycorrelated with BMC in the proximal humerus offrozen shoulder.

38 ULTRASONOGRAPHIC FINDINGS OF FROZEN SHOULDER.J.Urakawa,MD, M.Murakami,MD, S.Hukuda,MD, Deptof Orthopaedic Surgery, Takashima GeneralHospital, Minakuchi Shimin Hospital, Shiga Univ.of Medical Science.

We repoLta study of real time ultrasonographicexamination to specify the pathognomonic factorof frozen shoulder. Ultrasonography was per­formed in 30 patients who suffered from unilat­eral frozen shoulder. The examination con­sisted of two series. Firstly, observation ofeach component of the rotator cuff was per­formed and the thickness of it was measured.Secondarily, observation of the coraco-humeralligament was performed dynamically and stati­cally. The dynamic observation of the coraco­humeral ligaments was performed during themaximum internal and external rotation of theshoulder with special emphasis on elastisity ofthe ligaments. The static one was consist ofmeasuring of the length and thickness ofcoraco-humeral ligament. There was no signifi­cant difference in the thickness of eachrotator cuff component between the affected sideand normal one. As concerns the dynamic obser­vation of the coraco-humeral ligaments, theligament of the affected side was revealed toostiff to expand fully during external rotation,while the ligament of the normal side had muchelasticity. In conclusion, contracture of thecoraco-humeral ligament was highly suggested asa pathognomonic factor of frozen shoulder.

J. Shoulder Elbow Surg.January/February 1993

39 An Aproach to the Rotator-cuff tendinitis, as anOveruse Syndrome, through the Form Analysis.K. WATARAI, M.D. Dept of Sports Sciences, Collegeof Arts & Sciences, Univ. of Tokyo.

Purpose of this paper is to think about a mis­understanding of pitching form which causes achronic rotator cuff tendinitis. We have seen sometypical forms in the patients. We questioned theattitude of the upper extremety at some pitchingphase to 145 male students and 117 college andsemi-professional baseball players. The attitudewhich cause excessive rotation of the humeruswere shown in 49.6 % of students and 19.6' % of

players (10.3 % of the pitchers). We must know therational form for diagnosis and treatment of thethrowing arm injuries.

40 MANAGEMENTS FOR EPIPHYSIALDISORDERS IN THE SHOULDER CAUSED BYSPORT ACTIVITIES. Keizo Morisawa,MD,Yasufumi Kataoka,MD, Toshio Kitamura,MD,Makio Yamaga,MD &Katumasa Takagi,MD,Dept. of Orthoredic Surgery, KumamotoUniversity Medical School, Kumamoto,Japan

From January 1988 to June 1992, there were18 cases with epiphyseal disorders in theshoulder in our clinic. They were 17 male andone female (age 10-14). They contained 15 caseswith little league shoulder and 3 cases withacromional epiphysiitis. All of the cases weretreated conservatively. The cases with littleleaguf' shoulder were prohibited from throwingduring a certain time of periods.All of the cases recovered conservatively, but therecovery time of the cases with little leagueshoulder was usually longer than the others.Only ofle case recurred the same symptoms2 years after. Epiphyseal disorders in the

shoulder are not rare in young athletes.We should diagnose them as soon as possible,for in the early stage most of the cases recovereasily by conservative treatments.

J. Shoulder Elbow Surg.Volume 2, Number 7, Part 2

41 AN ANATOMICAL STUDY OF BICEPS TENDON/LABRUMCOMPLEX -A PRELIMINARY REPORT- M.Nariyama,MD,M,Abe,MD, M.Doi,MD, T.Onomura,MD, Dept ofOrthopedic Surgery, Osaka Medical college,Osaka, Japan.

(Purpose) The precise anatomical investi­gation of BLC (biceps tendon/labrum complex)has not been reported. This study was plannedto reveal the anatomical relationship betweenthe biceps tendon and the superior labrum.(Materials and methods) thirty one shoulderjoints from 20 cadavera were observed macro­scopically and microscopically. The age atdeath ranged from 48 to 92 years (mean 76years). The distance from the top of theglenoid to the point where the biceps tendonmerges to the labrum (BG distance) was measured,then the superior labrum with the biceps tendonwas resected, and stained with hematoxylin andeosin. (Results) Macroscopically, BG distanceranged from 6.9rnrn anterior to the top ofglenoid to 4.5rnrn posterior. The transitionfrom the tendon to the labrum was so smooththat their border could not be identified. But,microscopically, the collagen fibers of eachstructure could be clearly distinguished fromthe others. The connection between the tendonand the labrum was loose and no tight connectionwas observed. (Conclusion) The collagen fibersof the biceps tendon could be distinguishedfrom those of the labrum microscopically, andthe connection between them was loose in thesuperior part of the glenoid. These findingssuggest that this portion is one of the vulner­able site to injury.

42 SPECIFIC FINDINGS INDICATING DETACHED SUPERIORGLENOID LABRUM ON CT ARTHROGRAPHY AND MRI. K. IzawaM. Voneda & K. Hayashida, Dept of Orthopaedic Surgery,Osaka Kohsei-Nenkin Hospital. A. Hirooka, Sekime Hospital.

After detachment from glenoid rim, the biceps tendon andlabral complex (BLC) tends to transposed inferiorly, andbecame trapped between the humeral head and the glenoidfossa, often causing shoulder pain. This condition is calleddetached and floating BLC (D&F BLC). Few useful imagingtests for this injury have been reported, and it is usually onlydiagnosed by arthroscopy. In this study, we investigated thespecific features of D&F BLC on CT arthrography (CTA) andMRI. Pre operative CTA was performed in 25 patients withD&F BLC and MRI was also done in 13 of these patients. Ascontrols, we studied 40 patients who had no abnormalities ofthe BLC at arthroscopy. The specific CTA finding indicatingD&F BLC was the presence of the air between the superiorlabrum and the glenoid fossa, and this finding was recognizedin 12 patients who had D&F BLC (48%). In the control group,this finding was only noted in 2 cases. The specific MRIfinding indicating D&F BLC was a linear high intensity area atthe base of the superior labrum on T-2 weighted obliquecoronal views. This finding was recognized in 6 patients whohad D&F BLC (46%), while it was noted in only 1 of the controlgroup. Therefore, the specificity of CTA for D&F BLC was95% and the sensitivity was 48%, while the specificity of MRIwas 96% and the sensitivity was 46%.

Abstracts 543

43 ARTHROSCOPIC SURGERY FOR INJURED GLENOIDLABRUM. Y.Nakatsuchi ,MD., Y.Hata,MD. & S.Sai­toh,MD. Dept of Orthop. Surg., Shinshu Univ.Sch. of Med., Matsumoto, Japan.

Cases with shoulder pains during the move­ment caused by 1abra1 injury were reported.Ten cases with a range in age from 16 to 46years old were operated on. Si x cases hadepisodes of shoulder trauma and 8 had longtime sporting activity Double contrastCT-arthrography was performed in all cases.Partial resection of the labrum detachedfrom the glenoid rim and slipped into thejoint space was performed under arthroscopyin 7 cases, di rect repai r of the 1abrum andthe capsule in one case respectively andtenodesis of the long tendon of biceps wasaddeo in 2 cases. The postoperati ve fo 11 ow­up time was 3 to 15 months(9 months on anaverage). A superi or 1abra1 1esi on was foundartilroscopically in 9 cases consisting of 4cases of the superior labral lesion aloneand 5 of the lesion assoclated with otheri ntraart i cuI ar 1esi ons. The results in tenpat i ents were analyzed by the JOA scori ngsystem for the shoulder joint. Significantimprovement was found stat i sti cally in thetotal score and in the item of pain aswell. However, apprehension of the shoulderdislocation remained in two cases.

44 THE RESULTS OF ARTHROSCOPICSUBACROMIAL DECOMPRESSION FOR SHOULDERIMPINGEMENT SYNDROME.

E. shimozaki, Dept. of Orthop. Surg., Kanazawa Univ.Kanazawa, Japan

The purpose of this paper is to assess the results ofarthroscopic subacromial decompression (ASD) forshoulder impingement syndrome.

ASD was performed on 16 patients (18 shoulders). Theage of 12 men and 4 women ranged from 19 to 60 years(mean: 39 years). 13 shoulders were classified as stage IIand 5 shoulders as stage III. Follow-up period rangedfrom 6 to 36 months (mean: 21 months). The results wereevaluated on JOA shoulder rating score.

An average JOA score improved from 77.1 to 96.3points. There was significant improvement in pain, 15shoulders (83.3%) had satisfactory pain relief. There wereno complications, beside one patient with full-thicknessrotator cuff tear recieved reoperation with cuff repair.Three athletes in this series returned to prior sports levelwithout pain.

ASD allows a less scarring, procedure with fewercomplications and a thorough diagnostic evaluation of theglenohumeral joint and rotator cuff. Since the deltoidmuscle is not detached, patients can resume the activities ofdaily living immediately. In reviewing our results, ASD isrecommended as an alternative to open anterioracromioplasty in advanced impingement syndrome.

544 Abstracts

45 NEUROHISTOLOGY OF THE SUBACROMIAL BURSAEASSOCIATED WITH INCOMPLETE ROTATOR CUFF TEARY.TOMITA,MD,K.NAKAGAKI,MD,J.OZAKI,MD,S.TAMAI,MDDept. of Orthop. Surg., Nara Medical Univ.

The purpose of this study is to review theneurohistology of the subacromial bursae asso­ciated with incomplete rotator cuff tears. Bi­opsy specimens of the subacromial bursae wereobtained from 8 patients (8 shoulders) whounderwent surgery for incomplete cuff tear: 5bursal side tears, 2 articular surface tearsand a intratendinous tear. There were seven menand a woman with an average age of 48.3 years.The preoperative duration of sympoms rangedfrom one to 14 months(average, 6 months). Afterstaining using a modified gold chloride method,the serial sections were studied with a lightmicroscope. The subacromial bursae were denselysuppled with blood vessles and nerves. Howeverpopulation of nerve elements within a segmentof the bursa opposite torn cuff was thin aswell as blood supply. Nerve fascicles and bloodvessels lay within the subacromial bursae inclose association. The association of poorinnervation and blood circulation has consider­ed important in the development of rotator cufftear.

46 PATHOLCGICAL ClIANGES OF 'IRE ACRCMIOO ANDTHE (J)RACDACRClolIAL LIGAMEN!' IN THEPATIENTS WITH POSITIVE IMPINGEMENTSIGN.N.Suenaga,MD.A.Minami,MD.K.Suzuki,MD.Dept.of Orthopaedic Surgery ,HokkaidoUniv.Sch.of Med.K.Fukuda,MD.Dept.ofOrthopaedic SUrgery ,sapporo Shakai-HokenGeneral Hospital.

To define the pathanechanism of the shoulderimpingement syndrome, we investigated thepathological changs around the undersurfaceof the acranion and the coracoacranialligament (CAL) in the patients with positiveimpingement sign. Fifty acranions am CALswere obtained en block when Neer I s anterioracranioplasty was perforrred.These 50 shoulders were divided into three

greel's; 1 )impingement syndrane without rotatorcuff tear (13 shoulders) 2)no-traumaticrotator cuff tear (16 shoulders) 3)traumaticrotator cuff tear (21 shoulders)

Pathological findings of impingement syndranewithout rotator cuff were similar to 00­traumatic rotator cuff tear which pathologicalchanges were mainly founded at the site ofattachment of the CAL and little changeswere found at the undersurface of theacranion. These results suggested thatimpingement was one of major causes of 00­traumatic rotator cuff tear.

J. Shoulder Elbow Surg.January/February 7993

47 BONY SPUR OF THE ACROMION AND MORPHOLOGICALCHANGES OF THE ROTATOR CUFF (part 3).Kenro Matsui M.D., Tomonobu Miyazawa M.D. &Kiyohisa Ogawa M.D.* Dept. of Orthop •• Surg.,Saitama Medical School, Saitama.

In 1990, we have reported prelimina y studyfor bony spur of the acromion and morphologicalchanges of the rotator cuff. In 1991, we havereported 2nd study of the spur with asymptomaticshoulder and the result indicated that somefactor which makes small bony spur is subclini­cal impingement or physiological impingement.

In this paper we would like to clarify thefactor which increases the size of the spur.

Our subjects were 123 cadavers with 241shoulders. They were evaluated for the severityof injury to the rotator cuff and bony spurradiologically.

Normal or softening and fibrillation wasfound 80% of 186 shoulders has no or small spur.

Partial or complete tear was found more than60% of 55 shoulders has medium or large spur.

We consider that the factor which increasesthe size of the bony spurs is clinicalimpingement which represent by rotator cufftears.

48 II.TRASONOGRAPHY !F THE ROTAT(JI ClFF !F THE POSTlJPERATi VEPATIENTS WITH ROTATOR ClFF TEAR. II.Eto,II>, N. Ito. 11>. andK. Iwasak i,ll>, Dept. of Or thop. Surg. ,Nagasak i Un i v. Sch. of lied.

The purpose of th i s study was to invest igate the postoper­at i ve cond i t ions of rotator cuff of the pat ients with cufftear by ul trasonography.

Aloka SSO-620(7.5I1lz) was used for the study. Bi lateralshoulders of thirty-one patients were examined, whi Iepatients were sitting upright with the shoulder in the neu­tral position. The measurements were made in two planes,the transducer being placed in the fiber direction of thesupraspinatus muscle and also perpendicular to that.The average age of the pat ients was61 years (45 to 74 years).The follow-up per iod ranged from I tolO years (average; 5.7years).

There was no correlation between the thick ness of thecuff of the operated side with the age of the patients.Seven shoulders (23'0 showed normal sonograms, and twenty­four shoulders (7796) had abnormal sonograms which showedirregular echogenesity, echogenic foci, irregular superfi­cia I Iayer and th i nn i ng of the cuff, etc. The averageth i ckness of the cuff of the operated shou Ider was 5. 8± I. 9mm and that of the normal shoulder was 7. 2± 1. 3mm. There wasa statistically significant difference between the thicknessof the cuff df both shoulders. Thickness of the cuffdepended on the size of the tear, that is to say, the largerthe tear, the th inner the cuff. The pat i ents with the cuffof less thickness had poorer scores according to the evalua­tion sheet of the Japanese Orthopaedic Association.

J. Shoulder Elbow Surg.Volume 2, Number 7, Part 2

49 MR IMAGING DIAGNOSIS OF ROTATOR CUFF TEARS.

H. Munehiro. MD.K. Takata, MD. Takata Orthopaedic Hospital. Tokushima

Japan.

We performed a study to determine the usefulness of MR Imag­ing for the diagnosis of rotator cuff tears. Fourteen patients withrotator cuff tears confirmed at surgery were reviewed. Imageswere obtained on a O.2T permanent magnet system using spin-echopulse sequences with 5mm slices oriented in oblique coronal

planes.In 12 of 14 cases, MR Imaging showed discontinuity and high

signal in the rotator cuff, but in 2 cases with small tears thesedirect signs of rotator cuff tear were not identified. Retraction ofthe oupraspinatus tendon was shown in 2 of 4 moderate tears andall of 4 massive tears, and the extent of retraction could beaccurately 'lssessed. MR Imaging also depicted several soft tissue

and bony abnormalities.These results suggest that MR Imaging has good potential for

the diagnosis of rotator cuff tears even with a low·field-strength

MR unit.

50 MR IMAGING IN ROTATOR CUFF TEARS -Diagnosis ofFull-Thickness and Partial Cuff Tears - N.Ohyabu,MD, N. Matsui. MD. K. Sugimoto, MD. Y. Taneda,MD.&M.Maeda.MD* Dept of Orthopaedic Surgery. NagooyaCity University. Aichi. *Sankurou Hospital

Arthrography of the shoulder and subacromialbursography can not detect substantial changes ofthe rotatorcuff. We examined the shoulder jointswith rotator cuff injury with MR imaging. and thencompared them with operative findings. (Materials'and Methods) 22 patients 22joints(16 males.6

females.mean age55.2yrs). who suffered from rotatorcuff injury.~ere examined with MR imaging.MR

examinations were performed on Gyroscan O.5-T(Phil ips Medical System) and SMT100 1.0-T(Shimazu)with a circular surface coi I. Imagings were

performed in the anterobl ique coronal plane,parallel to the scapular spine.(Results andDiscussion) 6full-thickness cuff tears.14partialtears and 2 normal cuffs were exhibited inthe MR images. We observed 9 full-thickness tears.14 partial tears and no normal cuffs at surgery. Acomparison of the MR images and the operative

findings in the ful I-thickness tear showed asensitivity of 55.6~. a specificity of 92. 3~ andan accuracy of 77.3~. PPY was 92.3~ and NPY was 75.O~. On the other hand. a comparison in thepart iaI tear showed a sens it ivity of 87. 5~.

a specificity of 57. 1~ and an accuracy of 68.2~.

PPY was 53. 8~ and NPY was 88. 9~. MRimaging cannoninvasively detect the location and the size oftear and degeneration of the rotator cuff.

Abstracts 545

51 PATHOLOGICAL DEGENERATION OF TORN ROTATORCUFF BASED ON A MRI STUDY, Kimio Nakagaki. AmYasuharu Tomita, MD, liro Ozaki. MD, Susumu Tarnai. MD,Dept. of Orthop. Surg, Nara Med. Univ., Kashihara,Nlra,lAPAN.

If the degeneration of rotator cuff is advancedthe cellularity of the tendon is diminished.We com­pared the signal intensity of the torn cuff on MRim­aging wi th cellulari ty of the tendon And we studiedthe degeneration of torn cuff by MRI. Forty-oneshoulders with rotator cuff tears requiring repairwere scanned preoperatively in a O.5T MRI systemTl-weighted sequence, T2--weighted sequence, T2*-weig­hted sequence and proton-densi ty-weighted sequencewere performed. The specimens of the torn cuff edgeswere examined microscopically at a magnification ofX400 at three parts, and the number of tendon cellsin each part was calculated and averaged. In the shoul­der in which rat io of the signal intensi ty of thetorn cuff to the signal intensity of del toid muscleon Tl, T2, T2* and proton-density-weighted images wasincreased, the cellulari ty of torn cuff was diminished.

An increase in signal intensity of torn cuff on Tl,T2, T2* and proton-densi ty-weighted images wasassociated with advance of degeneration of torn cuff.The signal intensi ties of torn cuffs on T2, T2* andproton-densi tv-weighted images should be used forevaluation of degeneration of torn cuff rather thanTl-weighted image on which it is difficult to iden­tify the torn cuff edge.

52 MR IMAGING IN THE DIAGNOSIS OF INCOMPLETETEARS OF THE ROTATOR CUFF. H. Kumagai, MD, M.Mokasa, MD, T. Ishibashi, MD, & M. Tanaka, MD, *Deptof Radiology, Dept of Orthopaedic Surgery, TokyoMetropolitan Otsuka Hospital,Tokyo, Japan

Fifty-one cases were diagnosed to have incompletetears of the rotator cuff with MR imaging. In elevencases out of the 50, incomplete tears were surgicallyconfirmed(four bursal-side tears, two joint-side tears,and five intratendinous tears). The other 40 cased didnot undergo surgery. T1- and T2-weighted imageswere obtained along the oblique coronal plane in a1.5-T MR system. High signal lesions in the rotator cuffon T?-weighted images were showed in all the elevencases. In one of the eleven, the high signal lesion hadalmost full thickness of the rotator cuff, while in ten ofthe eleven, the high signal lesions had partialthickness. T2-weighted images mainly showedintratendinous part of the tears regardless ofperforation. Slightly increased signal lesions on T1­weighted images had full thickness of the rotator cuff inthe all eleven cases. Non-invasive MR imagingenabled us to diagnose incomplete tears of the rotatorcuff.

546 Abstracts

53 THE DIAGNOSIS AND TREATMENT OF JOINTSIDE ROTATOR CUFF TEAR BY OVERUSE INSPORTING ACTIVITY.Midorikawa.MD. Hara.MD. Shibata. MD. Izaki.MD and Ogata. MD. Dept. of Orthop.Surg..School of Med.. Fukuoka Univ.of Japan.(PURPOSE)The diagnosis of sportsinjuries of the shoulder is difficult.What is useful for diagnosis of them andhow we approach them?(MATERIAL andMETHOD)The subjects comprised 18cases(mean age:19.9) with shoulder pain insports and treated by arthroscopicsurgery as joint side rotator cufftear(JST).We performed plain X-ray. localanesthetic test(LAT).sonogram.MRI andarthrography before arthroscopy.(RESULTS)AII cases returned to theirsporting activity after arthroscopicsurgery and rehabilitation. (CONCLUSION)The LAT was useful for decide thelocation of pain. and sonography was mostuseful for JST.but we can·t diagnose JSTwithout arthroscopic examination.

54 ARTHROSCOPIC SUBACROMIAL DECOMPRESSION FORROTATOR CUFF TEARS. Masao Kurokawa and YasusukeHirasawa, Dept. of Orthopaedic Surg., Kyoto Pref. Univ. ofMed., Kyoto, Japan

We evaluated the outcome of arthroscopic subaromialdecompression (ASD), which was performed on 29 patients(15 male and 14 female) with rotator cuff tears ranging in agefrom 15 to 86 years (mean: 52 years). Postoperativefollow·up was continued for 12 to 51 months (mean: 29months). Rotator cuff tears included partial thickness tears in18 cases (2 Snyder classification A1, 2 A2, 2 A3, 5 B1 and 7B2), full thickness tears below medium grade in 5 cases andmassive tears in 6 cases. ASD was performed followingEllman's method, and postoperative evaluation was based onthe JOA (Japanese Orthopaedic Association) score which isthe usual criterion for assessing the outcome of treatment forshoulder joint diseases.

The JOA score of 16 of 18 (89%) patients with partialthickness tears improved from 75.9 ± 10.4 pointspreoperatively to 90.7 ± 6.4 points postoperatively. Inaddition, 4 of 5 (80%) cases with full thickness tears belowmedium grade showed a marked improvement from '66.8 ±14.3 to 83.8 ± 10.8 points. For these types of tears, ASD wasfound to be quite effective, since it relieved shoulder pain andimproved joint function markedly. In 6 cases with massivetears, pre- and postoperative JOA scores were 58.7 ± 7.4and 62.3 ± 7.8 points, respectively, showing no significantimprovement. Therefore, ASD is not indicated for cases withmassive tears. In addition, unsatisfactory outcomes wereattributed mainly to insufficient decompression in cases withpartial thickness tears and to dysfunction of the rotator cuff incases with full thickness or massive tears.

J. Shoulder Elbow Surg.January / February 7993

55 THE JOINT SIDE TEAR OF THE ROTATOR CUFF.Kaoru Yamanaka, M.D., Michihiro Kamata, M.D.,Hiroaki Nonomiya, M.D., Matsuyuki Simizubata,M.D., Takashi Matsumoto, M.D., YoshihisaSuzuki, M. D., Akeo Waseda, M. D., Shizuoka RedCross Hospital.

Fifty two cases of joint side tearsdiagnosed by arthrography were studied. Therewere 25 males and 27 females with mean age 60years old. Forty three cases were treatedconservatively and 9 cases were treatedoperatively. The initial score evaluated byJapan Orthopaedic Association Shoulder score(hereafter JOA score) was 67 points and thefollow-up JOA score was 83 points in theconservative group. The initial JOA score was59 points and follow-up JOA score was 93 pointsin thp operated group. Therefore, the prognosiswas better in the operative group thanconservative group. Follow-up arthrographieswhich were performed to the conservative groupdemonstrated the disappearance of the tearportion (4 cases), reduction of the tearportion (4 cases), enlargement of tear portion(20 case,,), development of a complete tear(5 cases). The prognosis appeared to besatisfactory when the joint side tear was smalland occurred in a young tendon with trauma inthe conservative group.

56 PATHOGENESIS AND SURGERY OF INCOMPLETE SUPER-FICIAL SURFACE TEARS OF THE ROTATOR CUFFJ.Ozaki,MD, H.Nakata,MD, H.Tatsumi,MD, T.Shimomura,MD, Y.Tomita,MD*, K.Nakagaki,MD*, Y.'Nakagawa,MD*, G.Sakurai*, Dept of OrthopaedicSurgery, Nara Prefectural Hospital, Hiramatsu,1-30-1, Nara, Japan, *Dept of Orthopaedic Surg.Nara Medical University, Nara, Japan.

(Purpose and Patients) This paper is todescribe pathogenesis and surgery of incompletesuperficial surface tears of the rotator cuffbased on our surgical experiences. Fifty-twoshoulders in 51 patients who had incompletesuperficial surface tears of the rotator cuffwere operated on between 1979 and 1990. Thirty­six patients were men and 15 were wemen, and anaveraged age was 50.8 years. (Results) Thislesion could be divided into two groups; theone was caused by overuse, and the other onewas caused by direct trauma. At operation, theseverity of this lesion could be classifiedfrom grade 1 to 4 (erosion, crater, stump,peeling-off) according to the torn shape anddepth. In this study, 46 shoulders in 45patients could be followed-up (av. 5 years).Fourty-one shoulders were graded excellent butremaining 5 shoulders, in which torn cuff wasrepaired with considerable tension, were gradedgood. Operation combining acromioplasty, cuff­mobilization and cuff-repair was effective.

1. Shoulder Elbow Surg.Volume 2, Number 7, Part 2

57 EVALUATION OF THE RESULTS OF THEPROCEDURE FOR IMCOMPLETE TEAR OFTHE ROTATOR CUFF K. Fukuda. M.D. et alDept. of Orthop. Surg. Saworo Shakaihoken GeneralHospital, Sapporo, JAPAN

The purpose of this paper is to evaluate theresults of the operative procedures for incompletetear of the rotator cuff comparing with the resultsfor complete tear.

(MATERIALS and METHODS) We operated15shoulders of the incomplete tear (group A) and 37shoulders of the complete tear (group B) of thesupraspinatus tendon. In groupA,8 bursal side tearsand 7 rim rents were involved. Neer's acrornioplas­ties were performed in all cases. In 7 cases,trimming and full-thickness resection at the end ofthe partially torn cuff and McLaughlin's suturewere performed. Side-to-side suture for 3longitudinal incomplete tears and simple suture fortwo flap tears were used. In group B, Neer'sacromioplasty and McLaughl in' s suture wereperformed. Average ages of group A and B were 48and 53 years old.

(RESULTS) According to the JOA evaluationsystem, 13 shoulders of the 15 incomplete tearshad excellent results and 2 were fair. One of 2fair results revealed re-rupture of the flaptear.

( CONCLUS ION) The resul ts suggested tomaintain the end of the partially torn cuff wasimportant. Trimming and special suture techniqueshuold be nesessory.

58 RESULTS OF SURGICAL TREATMENT FOR PARTIALTHICKNESS TEAR OF ROTATOR CUFF.T.Kutsuma, MD, M.Kamihira, MD, Dept. of Orthop.Surg., Kofu City Hospital, Kofu city, Japan.

Purpose: 41 cases of partial thickness tear of therotator cuff underwent surgical treatment during a16 year period from 1976. We made an evaluationof the 6-months-or-more post-<>perative results in 35cases using J.O.A. score.

Methods: The types of partial cuff tear were (1)joint side tear in 20 cases, (2) intratendinous tearin 4 cases and (3) bursal side tear in 11 cases.

Joint side tear was frequently positive forarthrogram (90 %) and color injection test. 72 % ofbursal side tear was positive for bursogram. To thecontrary, it is extremely difficult to diagnose theintratendinous tear preoperatively.

Neer's anterior acromioplasty was performed on allcases. Partial thickness tear was resected, and repairedmainly according to McLaughlin's procedure.

Results: The total score was improved from pre­operative mean of 58 points to a post-<>prative meanof 91 points. Most of the cases, or 23 cases (66 %),had a total score ranging from 91 to 100 points,followed by 8 cases (23 %) in the range of 81 to90 points. There were 4 cases (11 %) with a poorscore of 80 points or less.

Conclusions: In our procedure, anterior acromioplastywas performed to remove impingement; and at thesame time, any partial tear detected was resected,followed by repair at a normal site. We consider itimportant to make the bursal floor as smooth aspossible for the prevention of post - operativeimpingement.

Abstracts 547

59 ANALYSIS OF OPERATED CASES WITHINCOMPLETE ROTATOR CUFF TEAR. K.Ogawa,MD,A.Yoshida,MD, M.Takahashi,MD, & T.Matsumoto,MD.Dept of Orthop. Surg., Sch.of Med., Keio Univ., Tokyo.

Studied were 49 shoulders from 48 patients who hadundergone surgery. 88% were male, 52% under 45 y.o.,67% were injured in the dominant arm, and 65% hadthe history of single violence. In 93%, depression waspalpated at the site of the tear. Mean duration frominjury to surgery was 18.5 months (1-192 months). Interms of torn tendon, S.S.P. accounted for 63%, I.S.P.for 8%, and S.S.P.+ I.S.P. for 29%. As for the type oftear, bursal-side tears(6.S.T.) accounted for 49%,intratendinous tear (I.T.T.) for 16%, joint-side tear(J.S.T.) for 27%, and combined type for 8%. Onlyanterior acromioplasty was performed in 8.S.T. or J.S.T.that did not exceed one-third of whole thickness of thetendon. Anterior acromioplasty and tenoplasty weredone in the remaining shoulder. In the 40 shouldersthat could be followed postoperatively for more thanone year, results were excellent in 80%, good in 18%,and fair in 3%. These results indicated that anterioracromioplasty yielded satisfactory results in 6.S.T. orJ.S.T. that did not reach one-third and that tenoplastymight be required for incomplete tears that exceed one­third.