Snapping scapula caused by abnormal anterior angulation of superior angle of the scapula Naomi Oizumi, Naoki Suenaga, Akio Minami, Hiroyuki Kato, Norimasa Iwasaki, Hiroyuki Kamishima, Shintaro Yamane Department of Orthopaedic Surgery, Hokkaido University School of Medicine (Purpose) A case of snapping scapula which was diagnosed using 3D-CT and cineradiography was reported. (Case Report) A 20-year-old woman noticed crepitation around her left shoulder 4 years previously. Motion pain appeared one year prior. The initial examination revealed snapping of the scapula with crepitation during active abduction and flexion of the shoulder. She had full range of motion of the shoulder and no obvious muscle weakness. The abnormal anterior angulation of the superior angle of the scapula was observed in 3D-CT. Cineradiography showed that the fourth rib was filliped by the superior angle the of the superior scapula. angle of Partial the resection scapula of was performed 3 months after her first visit. Two months after the operation, snapping and pain were absent. (Discussion) Abnormal angulation of the superior angle of the scapula is relatively rare as the cause of snapping scapula. 3D- CT and cineradiography were useful to define the pathomechanism of the snapping scapula. We would like to discuss about the cause of the symptom. 103--
Osteoarthritis of the shoulder frequent corticosteroid injections caused by Tatsuya Masuko, Naoki Suenaga, Akio Minami, Hiroyuki Kato, Norimasa Iwasaki, Naomi Oizumi, Shintaro Yamane Department of Orthopaedic Surgery, Hokkaido University School of Medicine [Purpose] Adverse effects of steroid injections such as osteoporosis, tendon rupture and infection were reported. We present a unique case in which was occurred osteoarthritis of shoulder joint after steroid injections into subacromial bursa many times. [Case report] Since 1997, a forty-three year- male felt his right shoulder pain and went to old a local clinic. There, he was caught a diagnosis of "frozen shoulder". As a treatment, he received steroid injections to his right shoulder about 36 times in 18 months. In 1999,he couldn't elevate his shoulder and came to our hospital. Range of motion of his shoulder was severely restricted. X-rays of his shoulder revealed osteoarthritic changes without superior migration of humeral head. In MR' (T2WI), high intensity area was found at the insertion of supraspinatus tendon. We performed arthrodesis of his shoulder. [Discussion] We must keep in our mind that repeatitive injections of corticosteroid into the shoulder joint have a possibility of destruction of the articular cartilage severely. 104---
Resection of bilateral clavicular shafts in the case of sternocostclavicular hyperostosis of pustulotic arthroosteitis. Toshikazu Gibol, Atsushi Higashi2, Tomohiro Tanabe2, Hidekatsu Ichikawa2, Ichiro Miyagawa2, Takashi Matsushita2 1 Department of Orthopaedic Surgery, Ohno Central Hospital 2 Department of Orthopaedic Surgery, Teikyo University School of Medicine [Purpose] We report a good course after resection of bilateral clavicular shafts of sternocostclavicular hyperostosis of painful pustulotic arthro-osteitis (PAO). [Case] A 54 year old right dominant house wife who was affected by pustulosis palmo plantaris (PPP) 9 years ago complained of bilateral chest wall swelling, redness, and spontaneous pain. There had been no past history of PPP, and no inflammatory sign. Conservative therapy was non-effective, so we operated on her after 5 years from onset. We resected left clavicular shaft with periosteum the 2 cm lateral of the sternocostclaviclar joint to point of attachment of the coracoclavicular ligament. So she felt no dull pain and gained full range of motion of left shoulder joint immediately after operation. After two years we operated on another side for the same complaint. At 4 years after left side operation and 2 years after right side, her shoulder conditions were excellent, J.O.A. scores of her bilateral shoulders were 95 points respectively. [Discussion] No cause of PAO has been found, and there have been recurrent operated cases. To cut off the continuity between chest wall and scapula, we resected the clavicular shafts. She didn't suffer from pain and had full range of motion. [Conclusion] We think resection of clavicular shafts for painful PAO can be effective despite slight change of floating shoulder, if conservative therapy is not successful. 105
Deltoid muscle paralysis caused by intramuscular injection *Seiji Kondo, *Ho-Rim Choi, *Shinji Mishima, *Shin-ichiro Saito, *Hirosh Koshima **Kunio Ida, ***Takuya Shimizu, * Hisashi Iwata * Department of Orthopaedic Surgery * * Department of Health Science Nagoya University School of Medicine * * * Health Service Center Chukyo University The patient is a 25-year-old male, professional dancer. For premedication of general anesthesia, Atropine and Hydroxyzine are injected into his deltoid at 3-finger width below acromion. Three days later, he complained discomfort and swelling of his shoulder. At rest, the shoulder looked normal, but when abducted, the middle fiber of deltoid was paralysed and swollen because it was pushed out by contracted anterior and posterior fibers. Muscular strength of the deltoid was slightly decreased in the external rotation position of the forearm. Four weeks after the injury, there was no recovery. EMG analysis showed acute neurogenic injury pattern of the deltoid. Three weeks later, weak contraction was observed and EMG showed tendency of recovery. Twelve weeks after the injury, the muscle contraction recovered normal and the swelling of the middle fiber disappeared. In this case, we infer that the cause of paralysis is a selective injury to the branch of axillar) nerve to the middle fiber of deltoid. Although the intramuscular injection into deltoid is accepted in nursing textbooks, it should be avoided. 106
Abnormal elevation of unilateral scapula after the injury-a case report Takayuki Matsuhisa,Hiroald Tsutsui, Kenichi Mihara,Shigeru Hokari, Kazuhide Suzuki,Tomoyosi Uchikawa, Naoki Kan,Katsuhiro Ota,Daisuke Makiuchi Dept. of Orthop., Showa Univ. Fujigaoka Rehabilitation Hospital lack of response to conservative treatment,he entered our hospital on Jan.11,2000. As compared with right side,the left scapula was recognized the 6cm elevation. Shoulder muscles were no atrophy. The range of motion was 80 in flexion and abduction. There was no muscle weakness and no sensory disturbance. Although the head MRI shows the slight expansion of Sylvian fissure and atrophic changes of left temporal lobe,the cervical spine MRI shows nomal finding. There are no abnormality in the brain wave,also EMG and MCV are within normal range. After the therapeutic exercise was done,he left hospital on Mar.11,2000. Although the therapeutic exercise is done at present,abnormal elevation of unilateral scapula is remained. [Thinking Process) It was as symptom of the head or cervical spine,but analysisof image [Purpose] To discuss the etiology and the treatment for abnormal elevation of unilateral scapula after the injury. [Case Report] A 26-year-old male complained of abnormal elevation of unilateral scapula. He had traumatism by traficaccident on Aug.23,1999. A previous medicin had an opinion that within normal range by left shoulder MRI and head CT. Because of his was normal. Also brain on wave and EMG were no abnormality. The etiology on this disease is unknown. [Remaining Issues) (1)As to the etiology of this case (2)Approach to this case 107
A Case of Recurrent Anterior Dislocation of the Shoulder Associated with Irrepairable Disruption of the Capsule Noriko Okuyama Kiyohisa Ogawa Wataru Inokuchi Kiwamu Horiuchi Hiroki Yosida Department of Orthopaedic Surgery, Keio University School of Medicine We present a case of recurrent anterior dislocation of the shoulder associated with disruption of the capsule. (Case Report) The patient was a 23-year-old-male. His right shoulder was injured while playing volleyball at 13 years of age. After this, dislocation have occurred 10 times. Muscle atrophy was not apparent. Apprehension sign was positive both anteriorly and posteriorly. The range of motion was slightly restricted in elevation. Plain X-p showed Hill-Sachs lesion, but no apaprent Bankart lesion. An pnemo-arthro CT revealed extraarticular flow of air. At exploration, we fond that half of the subscapular muscle was replaced by fibrous membrane which covered the humeral head directly. The MGHL was intact. The anterior capsule was torn obliquely, and the course of tear, along with the IGHL, reached the anatomical neck. Ruptured capsule was displaced toward the scapular neck and retraced. To add to the Bankart repair, we carried out reconstruction of the ruptured thin capsule with a Teflon felt, and further Latarjet method. (Conclusion ) Recently, many cases of recurrent shoulder dislocation owing to capsule rupture have been reported. Most of them were repaired using primary suture. Since there had been the capsule retraction in our case, reconstruction of the capsule was required. We consider that such remarkable capsule retraction was the result of the absence of the traction force concomitant with joint motion from the attached subscapular muscle. Arthro CT is informative in the preoperative diagnosis of capsule rapture like this. 108
Epiphyseal separation of the distal clavicle similar to the Rockwood type- IV dislocation of acromioclavicular joint. Naruhiro Tanaka', Gen-itsu Yoshikawa', Seiji Hiraoka', Katsuhiro Horil, Mototsune Murakami2, 'Department of Orthopaedic Surgery, Shiga University of Medical Science 2Murakami Orthopaedic Clinic IV AC dislocation in adult is usually treated surgically. We are hopefully to be discussed if the selection of surgical treatment was appropriate on this juvenile [Purpose) Though distal clavicle injury in juvenile appears to be acromioclavicular (AC) dislocation, it is, in fact, more likely epiphyseal separation. However proximal fragment of distal clavicle usually slips out of the periosteal tube and displaces to superior, conservative treatment are usually taken since coracoclavicular ligament has been preserved with periosteal tube. We experienced the epiphyseal separation, similar to Rockwood type IV and treated surgically. [Case] A-twelve-year-old boy visited our institution complaining of the right shoulder pain by hitting his right shoulder on the ground at rugby game. Physical examination revealed the loss of the clavicle relief and limited range of motion. Radiologically proximal edge of the distal clavicle was displaced posteriorly. Similar to Rockwood type IV AC dislocation, we performed open reduction and internal fixation. [Discussion] The case of Rockwood type case and also any better diagnostic method in case classification of the injury and treatment are differentiated between juvenile and adult. - 109 --
Delayed brachial plexus paralysis subclavian pseudoaneurysm after fracture :a case report due clavicular to Kota Watanabe, Takashi Matsumura, Hitoshi Aiba, Hirobumi Yoshida, Shinobu Yashiro, Taku Yatabe, Yuichiro Shiromoto Department of Orthopaedic Surgery, Ohtawara Redcross Hospital (Materialos and methods) A 72-year-old man sustained a right clavicular fracture after a fall. A massive subcutaneous hemorrage was noticed, but he didn't visited a hospital. Four months after injury, he noticed a large swelling in the right supraclavicular fossa and paresthesia on the right arm. The patient was admitted to the hospital for further examinations. On examination sensory and motor weakness of C5-C7 area was evident. Thndon reflexes of the right arm were reduced. Delayed union of clavicle was seen on the X-ray. A 5 X 5cm subclavian pseudoaneurysm was seen on the angiogram. On electromyogram the lateral cord of brachial plexus was injured. We resected the aneurysm with the segment of the injured artery and performed End-to-end arterial suture. (Result) After surgery, patient's neurological condition had improved remarkably. (Conclusion) Clavicular fractures are common, but it is rare that delayed brachial plexus paralysis due to subclavian pseudoaneurysm occures. If a small tear occured on the artery it might lead to a pseudoaneurysm and delayed compression of the brachial plexus would occur. In the case with massive subcutaneous hemorrage on supraclavicular fossa after clavicle fracture we need a careful follow up. 110-
Coexistence of elastofibroma and bursitis at subscapular area in a young pitcher Hidekatsu Ichikawa 1, Tomohiro Tanabe 1, Satoshi Abel, Atsushi Higashil, Toshikazu Gibo 1, Ichiro Miyagawa 1, Arimi Harasawa2, Tetsuo Imamura3, Takashi Matsushita 1, 1Department of Orthopaedic Surgery, 2Department of Radiology, and 3Department of Surgical Pathology Teikyo University School of Medicine (Purpose ) Elastfibroma is benign tumor like lesion presenting painless mass. We present a case of the elastfibroma with symptom of snapping phenomenon after throwing in a young baseball pitcher. (CASE) A 19-year-old man,who was a recreational baseball pitcher, felt the snapping phenomenon of his right shoulder with the painless mass on his right scapular area. He complained the difficulty on throwing in cocking phase. On MRI findings, low intensity linear images were seen on Ti and T2 images, and enhanced image was depicted in the mass with low intensity. Surgical excision of the mass was done. Histological diagnosis was elastofibroma, and coexistence of bursitis was found above the elastofibroma. After operation he has no complaint on throwing. (Conclusion) Once the diagnosis of elastofibroma was made on the basis of characteristic findings on MRI, surgical resection is not first choice of the treatment, but surgical resection should be considered in the case with snapping phenomenon due to coexistence of elastofibroma and bursitis. -111
Secondary chondoromatosis of the shoulder. A case report. Wataru Ono, Jun-ichiro Hamada, Kazuya Tamai, Yasumori Koguchi, Hiroto Sonoda, Koichi Saotome Department of Orthopaedic Surgery, Dokkyo University School of Medicine [ Purpose ] Secondary chondromatosis is a relatively rare condition in shoulder disorders. We report a case of secondary chondromatosis of the shoulder. [Case report] A 14-year-old girl felt mild pain in her right shoulder without trauma in 1998. She visited a local hospital and was pointed out nodular calcifications in the right shoulder by X-ray examination. She was referred to our department for its further investigation and treatment. On clinical examination at the time of first visit she had moderate swelling in anterior region of the right shoulder. There was no loss of range of motion and no instability in the shoulder, and no general laxity. Radiograph showed multiple nodular calcification in axillary and subcoracoid region. MRI demonstrated many free bodies in the axillary pouch and subscapularis bursa. Arthroscopic surgery combined with minimal open surgery was performed to remove free bodies in February, 2000. Arthroscopy showed many cartilage-like free bodies and slightly hypertrophic synovium. Two hundred seventy-one free bodies were removed from the shoulder joint. Histological findings of these free bodies revealed hyaline cartilage with surrounding ring-like calcification. There was no evidence of chondrometaplasia in the synovium specimens. [ Conclusion ] Chondromatosis(include osteochondromatosis) of the shoulder has been reported 24 cases. We diagnosed this case as secondary chondromatosis according to histological findings of free bodies and synovium. 112
Extra-abdominal desmoid tumor around the shoulder joint misdiagnosed as adhesive capsulitis Takuya Watanabe, Naoki Suenaga Akio Minami, Hiroyuki Kato, Norimasa Iwasaki Naomi Oizumi, Shintaro Yamane Department of Orthopaedic Surgery, Hokkaido University We present 3 cases of extra-abdominal desmoid around the shoulder joint that were misdiagnosed as adhesive capsulitis. (Case 1)A 29 year old female complained of right shoulder pain and decrease of the range of motion (ROM) of the right shoulder. She was diagnosed as having adhesive capsulitis and treated conservatively by a local doctor. Her shoulder pain increased which led her to visit our clinic. CT and MRI showed soft tissue tumor in the subscaplaris. (Case 2)A 47 year old female complained of right shoulder pain and limit of the 130M of the shoulder. She was treated conservatively by a local doctor, but the therapy was not effective. Our examination employing CT and MRI depicted soft tissue tumor in the deltoid and the teres minor. (Case 3)A 57 year old female complained of right shoulder pain and limit of the ROM of the shoulder. She was diagnosed as adhesive capsulitis and treated conservatively by a local doctor, but her symptoms did not improve. CT and MRI showed soft tissue tumor surrounded by the subscaplaris, the teres minor, the pectoralis major, as well as the 1 st-3rd rib and the brachial plexus. In all cases, open biopsy was done, the pathological specimen indicated the proper diagnosis was desmoid. (Conclusion)Extra-abdominal desmoid around the shoulder joint is often exhibited as shoulder pain and decrease of ROM of shoulder. The symptoms are similar to those of adhesive capsulitis. It must be kept in mind that desmoid tumor is one of differential diagnoses of adhesive capsulitis. 113
Dysplasia epiphysealis hemimelica on the proximal humerus Yoshitada Sakai', Kenji Fujit al, Tetsuo Nakajima', Hiroshige Sakai', Kosaku Mizuno' 'Department of Orthopaedic Surgery, Kobe University School of Medicine [ Purpose] To discuss about the diagnosis and the treatment of dysplasia epiphysealis hemimelica on humerus. [Case report] A seven years old boy has been suffered from a limitation of range of motion on his right shoulder. There was no abnormality at birth and in his growth. Although his parents took him to a local pediatrician concerning the limitation of his right upper extremity, at eight months old, nothing was pointed out. At four years old, his parents took him to the local orthopedist again because of no apparent change of his range of motion. X ray at that time showed the dysplasia of right humeral head and he was referred to our hospital. Physical examination revealed normal grown Asian boy with bony protrusion (acromion) on lateral aspect of his right shoulder. Right humeral head was not detected on the glenoid fossa, it existed at anteoinferior of it. X ray showed the dysplasia and inferior shift of right humeral head. CT arthrogram showed the defect of posterolateral aspect of humeral head and the congruity of grenohtimeral joint was not matched at all. The signal of existed humeral head on MRI revealed intermediate in both Ti and T2 weighted images. We also found a dysplasia of talus of his left ankle. [ Medical approach ] We diagnosed him as a dysplasia epiphysealis hemitnelica. Since he has no limitation of his activity of daily life, we did not do any surgical treatment and have been followed him once a year. [ Remaining issue ] We diagnosed from the appearance of X ray of his shoulder and talus. But, are we right? What is the differential diagnosis? Is any surgical treatment recommended? 114
A Case of bilateral Stiff Shoulder associated with Dupuytren's Disease Norikazu Ichikawa 1, Eichi Itadera 1, Takao Oomori 1, Hiroyuki Hashizume 2, Hajime Inoue 2 1 Dept. of Orthop. Surg., Kochi Prefectural Aki Hospital 2 Dept. of Orthop. Surg., Okayama University Medical School [ Purpose ] Bunker ( 1995 ) described the histological findings of the coraco- humeral ligament and the rotator interval of the capsule in the primary frozen shoulder and found them to be similar to those seen in fibromatoses such as Dupuytren's disease. We reported a rare case of the bilateral shoulder stiffness associated ' with a concealed rotator cuff tear and Dupuytren's disease. [Case Report] A 63- year- old man had left insidious shoulder pain since Apr., 1987. He admitted in our hospital Jan. 1992. He had night pain and severe painful restriction of left shoulder. Shoulder arthroplasty was carried out with a resection of a coracohumeral ligament and rotator interval. But he had a right shoulder pain after stumbled and fell in Jul.,1997, and admitted after three months. The surgical procedure was the same. Arthroscopy revealed congestive vascular synovitis. On histologic evaluation of the subacromial bursa, hypovascular fibrous connective tissue was present. On the other, the synovial inflammatory reaction was observed in the capsule. [ Discussion ] Restriction in shoulder motion has been reported after low - level trauma. We reported a case who was present with painful stiffness after a concealed rotator cuff tear. An association between a clinically frozen shoulder and Dupuytren's contracture was noted. Investigation has also centered on identifying a predisposition for stiffness. But factors that predispose the shoulder to stiffness has not been evident. 11 5
Rapidly progressed humeral head destruction after arthroscopic subacromial decompression -a case report- Takashi Kobayashi ', Akio Y okogawa ', Yasushi Mizumotol, Tomohiro Ojima' ' Department of Orthopaedi c Surgery, Ishikawakenn Saiseikai Kanazawa Hospital [ Purpose I Arthroscopic subacromial decompression improves the symptom of the rotator cuff tear, especially in small tear. Subacromial decompression for massive rotator cuff tear sometimes aggravates the shoulder function. We report the Rapidly progressed humeral head destruction after arthroscopic subacromial decompression. (case report) 68y.o., woman. Minor trauma caused her shoulder pain in November 1999. Evaluation of JOA score was 60 points (5-5-28-5-15). After the operation, she was suffrerd from 30 to 50 ml hydroarthrosis. Fracture of the acromion aggravated high riding humeral head and humeral head destruction. JOA score got worse to 35 points (5-6-8-1-15). The salvage operation was hemiarthroplasty combined with latissimus dorsi flap. ( discussion Subacromial decompression destroys the C-A arch, and then subacromial decompression for massive rotator cuff tear sometimes causes high riding humeral head and aggravation of the shoulder function. We thought the causes of humeral head destruction in this case were sensory disturbance due to diabetes and high riding humeral head, that was aggravated by fracture of acromion. We concluded that the adequate first operation was ratator cuff repair or rotator cuff reconstruction, e.g. latissimus dorsi flap, without acromioplasty. 116
ROTATOR CUFF TEAR CAUSED BY A SCREW USING IN THE ORIF OF DISTAL CLAVICULAR FRACTURE Jun Hashimoto Toshinori Kondo Masahiko Kornai Takashi Hashimoto Katsuya Nobuhara Nobuhara Hospital & Institute of Biomechanics Recently, the acromio-clavicular plate has been used for the ORIF of the distal clavicular fracture. In this time, we will report the rotator cuff tear which seems to be caused by a screw using for the fixation. The patients was 61 years old. He was injured to be caught by a machine on the job at the Oct. 30 in 1999, and brought to the emergency hospital. The bilateral clavicular fractures, rib fractures and pneumo-hemothorax were diagnosed. One months later, the right side of clavicular fracture was operated to be fixed at another hospital with using the plate. Since the sur- gery, he has been felt a shoulder pain during his reha- bilitation problem. He admitted to our hospital at the Feb. 10 in 2000, and the rotator cuff tear was diag- nosed by the arthrogram. He underwent a repair of the teared rotator cuff at the Feb. 24. The operative findings showed a lot of the scratches and the longitudinal tears on the supraspinatus tendon. Beneath the distal clavicular, the tip of screw penetrated the clav- icular with 3 millimeters length. This screw was removed and these longitudinal tears were sutured by side to side technique. In present, he dose not have any pain and has full range of motion. [CONCLUSION] It should be careful to use the plate or acromio-clavicular plate for the RIF of the distal clavicular fracture. 1 1 7
Partial tear of the tendon of the long head of the biceps (LHB) in three patient. Toyohisa Naniwa", Kiyohisa Ogawe, Wataru Inokuchi2), Noriaki Nakamichi2), Shuuzou Kobayashi2) 1)Saiseikai Mukoujima Hospital 2)Keio University [Purpose] We encountered three patients who had sustained sport injuries with characteristic findings of partial tear of the tendon of the LHB. [Materials] The subjects ranged in age from 24 to 40 years. The tendon tear had occurred in the right hand. Two of the patients had sustained contusions on the anterior aspect of the right shoulder during Judo and the third during Rugby. They experienced pain on horizontal abduction and external rotation. [Results] Tenderness was noted extending from the bicipital groove(bg) to the lesser tubercle in all the patients. All patients, pain occurred on the anterior surface of the shoulder during Yergason's test. In two of the patients, the tendon of the LHB within the BG appeared thin and its inferior part appeared thick on arthrography. MRI revealed retention of synovial fluid within the joint in all cases; however, it was difficult to confirm any tendon injury of the LHB. Contrast-enhanced CT revealed only flatness of the medial border of the BG. The diagnosis of partial tear of the tendon of the LHB was confirmed by arthroscopy. Fusion of the tendon of the LHB to the BG was performed. [Conclusion] No characteristic clinical manifestations are commonly observed in tendon injuries of the LHB associated with underlying degeneration in middle-aged and elderly persons. However, when tendon rupture occurs secondary to traumatic injuries in the absence of degeneration, the patients experience pain during exercise. Since diagnostic imaging methods fail to reveal partial tear of the tendon of the LHB, arthroscopy is necessary for a definitive diagnosis for partial tear of the tendon of the LHB. - 118-
Postoperative evaluation of Bankart repair method using suture anchor with MRA and arthroscope. Kazuhide Suzuki, Hiroaki Tsutsui, Kenichi Mihara, Shigeru Hokari, Tomoyoshi Uchikawa, Naoki Kan, Katsuhiro Ohta, Daisuke Makiuchi, Takayuki Matsuhisa Dept. of Orthop., Showa Univ. Fujigaoka Rehabilitation Hospital clarify the problem of the open Bankart [Purpose] The purpose of this study is to repair with MRA and arthroscopy. [Subjects and Methods] We studied 18 cases (man of 16 cases, woman of 2 cases) with the recurrent anterior dislocation or subluxation after surgery. Patients ranged in age from 17 to 58 years (average, 27.8 years). MRA was performed after the operation at average 12.9 months and arthroscopy was performed at average 13.2 months. In MRA with the obliqu axial image in ABER position, we evaluated the loosening and the reattached position of AIGHL. In the arthroscopy, 1) the deviation of anchor, 2) the loosening of the suture, 3) the existense of limited contact, 4) the condition of AIGHL, were observed and evaluated. [Results] MRA(ABER image) demonstrated normal AIGH-labral ligamentous attachments in 15 cases(83% ). Loosening of AIGHL were recognized in 4 cases (22%) in MRA. In the arthroscopy there was no deviation of anchor and limited contact. The loosening of suture was recognized in 5% of the sutured division. Normal tension of AIGHL were seen in 16 cases(89% ) but the space in anterior recess exited on 2 cases (11%). [ Conclusion] The reattachment of AIGHL-labral complex was satisfactory and there was no problem of limited contact said until now. 119--
MR1 Evaluation of the AIGHL in and External Rotation Positions -second report- Yoshinori Takubo ",Yasuto Fukui ",Mikihito Tamai 1Moloyuki Hore,Masao Kurokawa Yasusuke Hirasawa 1) Department of Orthopaedic Surgery, Olsu Municipal Hospital 2) Department of Orthopaedic Surgery, Kyoto Second Red Cross Hospital 3) Department of Orthopaedic Surgery, Saiseikai Suita Hospital 4) Department of Orthopaedic Surgery, Kyoto Prefectural University of Medicine [Purpose] We investigated the utility of MR imaging of the shoulders in abduction and external rotation position (ABER method) for evaluating the anterior inferior glenohumeral ligament (AIGHL). (Materials and methods] Seventeen shoulders of 17 patients (age ranged from 17 to 47 years old, average 27.6 years old ) with traumatic anterior glenohumeral instability were examined. Six shoulders were first dislocations and 11 shoulders were recurrent anterior dislocations. T2*-weighted images with 3D-FT technique (2mm continuous slices) were obtained in ABER position with superconducting MR imager (1.5 tesla). According to the MR images obtained in ABER position, the shoulders were classified into two groups : group A with well delineated anterior capsule, and group B without one. Arthroscopically, the shoulders with thick and wide AIGHL were regarded as AIGHL(+) and those with thin or no AIGHL as AIGHL(-). We compared the classification on the MR images with arthroscopic conditions of the AIGHL. [Results] Seven out of 9 group A shoulders were AIGHL(+), and all eight shoulders of group B were AIGHL(-). The sensitivity and specificity of MRI evaluation were 100% (all of seven shoulders) and 80% (eight of 10 shoulders) for prediction of AIGHL condition. [Conclusion] MR imaging with the ABER method was useful for evaluating the condition of the AIGHL. 120
MR Imaging of the subscapuralis tendon after an open Bankart procedure Katsunori Suzuki', Hisashi Yoshimoto2, Naohiro Sawaguchil, Akihiro Hatayamal, Kimihiko Iwasaki' Department of Orthopaedic Surgery, Oji General Hospital 2 Department of Orthopaedic Surgery, Kobayashi Hospital The purpose of this study was to evaluate the MRI findings of the subscapularis in patients who had an open Bankart repair. M&M: The subjects consisted of eighteen patients who had traumatic, unidirectional anterior instability with a Bankart lesion of the shoulder which was managed with open Bankart repair. The subscapularis tendon was taken down in thirteen patients, and split in five patients. The detachment of the anterior glenohumeral ligament was fixed with suture anchors. The mean duration from the operation to MRI was twenty-two months (range, twelve to thirty-six months). T1-,T2- and proton-density- weighed images were used to assess the subscapuralis and supraspinatus in the axial and oblique corona]. planes. Results: Two patients (11%) had a single episode of dislocation and subluxation. There was no signal change of the subscapularis muscle belly in either group on Ti-weighed images. All patients had a good contour of the subscapuralis on the axial T2-weighed images. Subscapuralis taken-down: Five patients (38V had a heterogeneous signal within the repaired site of the subscapuralis tendon. One who suffered a dislocation had a partial (50%) tear of the articular side of the subscapuralis and a complete supraspinatus tear. The other who had a subluxation had a heterogeneous signal within the subscapuralis tendon. Subscapuralis splitting: Two patients (40) had a focus of high increased signal intensity at the undersurface of the subscapuralis. Conclusion: Postoperative MRI showed irregularity of the repaired subscapuralis in 60% of the patients who had an open Bankart procedure. 121
MRI Evaluation of Bankart lesion in Abduction and External Rotation Positions Yasuto Fukui 1), Yoshinori Takubo 2),M iki hi to Tamai 4),Moloyuki Horii 4),Masao Kurokawa 3), Yasusuke Hirasawa 4) I) Department of Orthopaedic Surgery, Kyoto Second Red Cross Hospital 2) Department of Orthopaedic Surgery, Otsu Municipal Hospital 3) Department of Orthopaedic Surgery, Saiseikai Suita Hospital 4) Department of Orthopaedic Surgery, Kyoto Prefectural University of Medicine [Purpose] We investigated the utility of MR imaging of the shoulders in abduction and external rotation position (ABER method) for evaluating Bankart lesions(bl). (Materials and methods] Fourteen shoulders of 14 patients (age ranged from 18 to 47 years old, average 30.2 years old ) with traumatic anterior glenohumeral instability were examined. T2*- weighted images with 3D-FT technique (2mm continuous slices) were obtained in both ABER and adduction positions with superconducting MR imager (1.5 tesla). In some patients, MR findings for the anterior labrum included high signal intensity, unclear appearance, dislocation, disappearance, and fracture or bone defect of the anterior glenoid rim. These findings were regarded as BE_ Arthroscopically, the anterior labrums were evaluated in the range from I to 5 o'clock. On MR images, regarding anterior edge of glenoid rim as linear line, the anterior labrums were evaluated in the range from a sixth to five sixths of all slices with glenoid cavity. The range of anterior labrum of MR findings corresponding to arthroscopic findings was presented with a percentage. The significant difference between ABER method and adduction position was regarded as more than 10%. [Results] In evaluation for BL and normal labrum, six out of 14 shoulders (42.9%) were more useful with ABER method than with adduction position. Two shoulders (14.2%) were more useful with adduction position than with ABER method. The others (six shoulders: 42.9) were almost equivalent. [Conclusion] MR imaging with the ABER method was useful for evaluating the range of the Bankart lesion. 122
Imaging evaluation of anterior structure after open Bankart procedure Suture anchor vs Conventional method Kenji FtAjital, Hiroshige Sakai% Yoshitada Sakai' Yasunobu Iwasaki', Yuichi Hoshino, Kosaku Mizunol 1 Dept. of Orthop. Surg., Kobe University 2 Dept. of Orthop. Surg., Shinsuma Hosp. [Purpose] The purpose of this study is to evaluate the predictability of open Bankart procedure with suture anchor (SA) by comparing the imaging appearance of anterior structure in postoperative CT or MR arthrogram to the conventional method (CO). [Materials and Methods] Forty patients were evaluated (SA: 20, CO: 20). Bankart procedure was performed with intra- articular approach. Mini revo screw (Zimmer), MitekGII, or Panalok (J&J) was used for suture anchor technique. CT or MR arthrogram was performed 6 months after the operation to evaluate the anterior structure of the shoulder. Clinical evaluation was also performed using JOA shoulder instability score. Results No apparent difference was found by CT or MR arthrogram between SA and CO. Clinical score was also not significantly different between them. [Discussion] The contact area between repaired labrum and the edge of glenoid using suture anchor has been reported to be smaller than using conventional method. But this study showed no apparent difference between those procedures both in post operative GT or MR arthrogram and clinical evaluation, suggesting that suture anchor can be safely used for open Bankart procedure. - 123 --
Hypoplasia of the Acromion correlated with Loose Shoulder ; the study of the three dimensional analysis Toshinori Kondo, Hiroaki Inui, Jun Hashimoto, Katsuya Nobuhara Nobuhara Hospital and Institute of Biomechanics [Purpose] There is characteristic feature such as a deficiency of the posterior margin of the glenoid and the hypoplasia of the acromion in the loose shoulder. We reported at the 21th JSA meeting about the correlation between the hypoplasia of the acromion and loose shoulder by the findings of rentogenograms. This time it was evaluated three dimentionaly. [Materials] The subjects were consisted of 30 loose shoulders (group LS) and 50 normal shoulders (group N). [Methods] 3D-MRI (SIEMENSE) imaging was extracted in the supine position. The images were put into the three dimentional analysing software (3D Virtuoso UA30A). It makes possible to detect the point or the plane voluntarily. The following measurements were evaluated 1) the anterior transverse diameter of the acromion 2) the distance(rr) between the right angle of the acromion and the medial right angle 3) the angle(r) with the anterior lateral edge and the right angle and the scapular spine [Results] There were significant differences between group LS and group N in the anterior transverse diameters, the Rr distances and the R angles. [Conclusions] The hypoplasia of the acromion could be found in louse shoulders, especially the bony structure from the right angle to the distal part is undeveloped and the right angle tends to be round. 124--
Study on the conservative treatment for shoulder instability Yushi Hasimoto, Anri Watanabe, Hisashi kurosawa Dept of Orthop Surg, Juntendo Univ [Purpose] The purpose of this study is to evaluate the results of the conservative treatment for shoulder instability. [Materials and Methods] Between 1981 and 1999, 35 patients, 56 shoulders (41 loose shoulder, 7 voluntary dislocation, 5 positional dislocation) were treated conservatively. The mean age at first visit was 21.4 (8-47) years old, the duration of follow-up was 12.2 (2-18) years. Occasion of the symptom, restriction of daily and sports activities, were researched by medical examination and questionnaire. [Results] Complaint caused by unknown occasion in 77% of cases, the duration until the first visit was over 1 year in 77% of cases. Muscle stiffness, a sense of incongruity, fatigue easily were complained frequently. Restriction of ROM were observed in 8% (flexion), 13% (ER), 21% (IR) of cases, any restriction of ADL were 49%. In 59% of cases restricted or gave up sports. Depend on the survey, prognosis were, 49% (no change), 34% (Improve), 14% (cure), 3% (worse). [Conclusion] To improve the shoulder Instability using conservative treatment, It is important to restrict of daily and sports activities, and explain to patients in detail. 125---
Glenohumeral Ligament in the stable shoulder joint and atraumatic structural dislocation Toshio JIL Bayley Kitamura Kumamoto Orthopaedics Hospital Royal National Orthopaedics Hospital, UK [Purpose) We will show the basic data as a normal appearance of the glenohumeral ligament (GHL) in stable shoulder joints, in thinking of the causes of the shoulder instability. (Materials and method) We selected 219 cases out of 484 cases with impingement syndrome which did not have any instability and inflammation under arthroscopy and anesthesia. We examined the rate of appearance of GHL both in stable joints and 16 atraumatic structural dislocations. (results) Absent rates are : SGHL 47%, MGHL 2.5%, IGHL 8.9%, MGHL and IGHL 0.5% within the stable joint group. Absent rates are : MGHL 25%, IGHL 75%, MGHL and IGHL 25% and only IGHL 50% within atraumatic structural dislocation group. [conclusion] These absent rates didn't show the true anatomical absent rate of the GHL. The reason is that it is difficult to ascertain whether ligaments are overstretched or missing completely through arthroscopy. In this point, this study is important in thinking of the causes of atraumatic structural dislocation through arthroscopy. There are higher absent rates in atraumatic structural dislocation. 126
Thermal Capsular Shrinkage for Nontraurnatic Shoulder Instability. Kenzi Okamura, Keiko Kagaya, Toshiro Takiuchi, Toshiaki Hirose, Mituhiro Aoki, Seiichi Ishii. Dept. of Orthop. Surg., Sapporo Med Univ [Purpose] The purpose of this study was to evaluate the arthroscoplc thermal capsular shrinkage for nontraumatic shoulder instability. [Patients & Methods] Seven patients were followed up over 12 months after surgery. There were 4 males and 3 females.the mean age at surgery was 19.7 years(15-28). Five of 7 were multidirectional instabillty(mdi). There were 2 baseball players, a gymnast, a basketball player and a archery player. We performed arthroscopic thermal capsular shrinkage by using YEPR System(Mitek Co.). We evaluated clinical results according to the Bigliani scoring system and level of the sport activitis. [Results] The overall results were excellent In 1 shoulder, good in 6. The average of the total score was 4.5 preoperatively and 7.0 postoperatively. Two baseball player, a gyrrinast and a basketball player returned to the games after three months and a archery player did after six months postoperatively. [Conclusions] Thermal capsular shrinkage Is usefull for nontraumatic shoulder instability especially for sport players. - 127 -
Thermal Capsular Shrinkage for Habitual Posterior Dislocation of the Shoulder Yuzuru Yamamoto', Motohiko Mikasa2, Hiroshi Mi yazawa 'Dept. of Ortho ic Surg., Nihon Kohkan Hospi tal 2 D ept. of Orthopeadic Surg., Tokyo Metropolitan Ohkubo Hospital 3 Dept. of Orthopeadic Surg., Showa Univ. School of Medicine [Purpose] The purpose of this study was to evaluate the arthroscopic thermal capsular shrinkage for habitual posterior dislocation of the shoulder. [Materials and methods] Case 1: 32 years old man is a body-builder, has trained at the bench-press. He had pain in his left shoulder since 27 years old In the first physical examination he had a posterior dislocation with forward flexion and a click with horizontal abduction, sulcus test was negative. Case 2: 24 years old woman had episodes like a dead arm syndrome at 14 years old and 20 years old After second episode she had pain in her right shoulder. In the first physical examination she had a posterior dislocation with forward flexion and reduced with horizontal abduction, sulcus test was negative. Case 3: 20 years old man has felt an uncomfortable sensation of instability with forward flexion 90' in his right shoulder since 19 years old while he had no cause. In similar he had a posterior dislocation in the first physical examination. sulcus test was positive. For these 3 cases we performed arthroscopic thermal capsular shrinkage by using VEPR system. We evaluate post operative results according to the Bigliani rating system and JOA score. The follow up period were 14 months in Case 1, 8 months in Case 2, and 7 months in Case 3. [Results] All cases were excellent in Bigliani rating system and were 100 points in JOA score. [Conclusion] The thermal capsular shrinkage is useful for habitual posterior dislocation of the shoulder in the short term results. 128
Electrothermal assisted capsulorrhaphy for shoulder instability Yusuke lwahorii, Hirokatsu Hanamura2, Masahide Yokoi1, Keiji Sato' Department of Orthopaedic Surgery, Aichi Medical University School of Medicine 2Kasugai Orthopaedic Hospital [Purpose] The purpose of this study was to evaluate the arthroscopic electrotherrnal assisted capsulorrhaphy (ETAC) for shoulder instability. [Material and Methods] Fifteen shoulders of the 15 patients with shoulder instability were treated with ETAC and reviewed. There were 9 males and 6 females. The mean age at operation was 24.1 years old (17-37) and mean follow-up period was 7.4 months (6-13). The shoulders included 8 anterior instability, 4 posterior instability, and 3 multidirectional instability (MDI). There were 8 patients with generalized joint laxity and 10 sports athletes. Lax redundant capsules were observed arthroscopically in the all patients. ETAC was performed using VAPR System. We evaluated recurrence of instability and clinical results according to the JOA Shoulder Instability Score (JOA-S1 Score). [Results] One patient with MDI developed recurrence of instability. Other patients restored stability and most have returned to their previous level of work or sports participation. The average of the JOASI Score was 51 preoperatively and 89 postoperatively. [Conclusion] These early results show that ETAC is a worthwhile method of treatment for the shoulder with a lax redundant capsule. 129
Clinical Results of Surgical Treatment for Posterior Instability of the Shoulder Tadashi Tomonaga, Masao Eto, Masahiro Wada Department of Orthopaedic Surgery, Nagasaki University School of Medicine (range; 13 to 29 years). The average follow-up period was 8 years one month (range; 7 months to 18 years 8months). In the first 4 cases, we followed Scott's original method and tightening of posterior capsule. The remaining 12 patients were operated on by the modified Scott's procedure and tightening of posterior capsule. All the patients were evaluated by the shoulder evaluation score of the Japanese Orthpaedic Association. [Results] Pre-operative average point of JOA score was 74.8 points, which improved to 93.8 points at the final follow-up. Recurrence was observed in 2 cases, which had voluntary [Purpose] In this paper, we report the results of posterior glenoid osteotomy (Scott) for posterior instability of the shoulder [Materials and Methods] From 1978 to 1997, we operated on 16 patients of posterior shoulder instability at our hospital. There were 10 males and 6 females with a mean age of 17 years posterior subluxation. One of them also had general joint laxity. All except these two patients showed no difficulties in ADL and sports activities. [Conclusion] From this study it can be suggested that satisfactory results can be obtained in the patients with posterior shoulder instability by posterior glenoid osteotomy. 130
Three-dimensional Computed Tomographic Evaluation of Glenoid Morphology in Traumatic Anterior Glenohumeral Instability Hiroyuki Sugayal, Noriyuki Ishige2, Koji Fujita3, Joji Moriishi2, Akihiro Tsuchiyal, Takeyuki Okazakil 'Department of Orthopaedic Surgery and Sports Medicine, Kawatetsu Chiba Hospital 2Matsudo Orthopaedic Hospital 3Department of Orthopaedic Surgery, School of Medicine, Chiba University [Purpose] The purpose of this study is to introduce a simple method of evaluating the shape and quantity of osseous defect of the glenoid rim using three-dimensional computed tomography (3Der). [ Materials and Methods Glenoid morphology of 47 consecutive shoulders in traumatic anterior glenohumeral instability, including 6 acute glenoid rim fracture, was evaluated through the use of 3DC1; which were also compared with 13 normal shoulders. Humeral head was deleted during the process of creating reconstructed 3D images. A ratio of osseous defect (fragment) against the outer fitting circle of the lower part of the glenoid contour (from 3 o'clock to 9 o'clock) was obtained by 3D images viewed from the perpendicular direction to the glenoid surface. [ Results] Twenty-seven out of 41 chronic cases (65.9%) had osseous defect. Average ratio of the osseous defect was 8.0 (range, 1.3-26.9) % in chronic cases and 24.3 (range, 113-343) % in acute cases. Acquired morphologic abnormality was seen even in 10 out of 14 no defect glenoids. Only one chronic case with 26.9% of defect was treated open with bone grafting. Others were treated arthroscopically without bone grafting. [Conclusion] The unique imaging technique of this study enables precise morphologic and quantitative evaluation of glenoid and would be a great asset in the preoperative decision making of the surgeons. 131
Surgical anatomy of glenoid rim fractures associated with traumatic shoulder dislocation Kazuya Tamail, Akio Masuda2, Jun'ichiro Hamada', Wataru Ohnol, Koichi Saotomel ' Department of Orthopaedic Surgery Dokkyo University School of Medicine 'Department of Orthopedic Surgery, Mitsui Memorial Hospital, [Purpose] To depict pathoanatomy of anterior glenoid rim fractures associated with anterior shoulder dislocation. [Patients and Methods] We reviewed operative findings of eight shoulders in eight patients who underwent open reduction of fractures of the anterior glenoid rim. The age of the patients ranged from 22 to 71 (median, 56) years. Four of the eight patients had additional injuries in the ipsilateral shoulder. All the patients had received closed reduction of shoulder dislocation on the day of injury. Open reduction and internal fixation of the rim fracture was performed 5-66 (median, 14) days post injury. [Results] The extent of the bony rim defect caused by a fracture measured 25-75 (mean, 55) % of the craniocaudal length of the entire anterior rim. In all the patients, the labrum was firmly attached to the displaced fragment and to the intact rim away from the fracture, but was detached of the rim in the immediate neighborhood of the fracture. In two patients, the fractured fragment was inverted posteriorly over the articular surface of the glenoid fossa. [Conclusion] Glenoid rim fractures associated with shoulder dislocations go together with injury of the glenoid labrum that is more extensive than the fracture. Surgical repair of both the rim fracture and the labral injury is required. 132
Stabilizing mechanism of modified Boytchev procedure ---A pressure between the humeral head and the subscapular tendon--- Yozo Shibata, Koji Midorikawa, Katsumi Yano, Noriaki Honjo, Masatoshi Naito Dept. of Orthop. Surg. Fukuoka University (Purpose) During Boytchev procedure, we can confirm that the shoulder joint does not dislocate at abducted-external rotated position as soon as the coracoid process is reattached. It was suspected that a tension of the subscapular tendon(sst) was increased by the transposition of the conjoined T. (Patients and methods) Pressure between the humeral head and the SST was determined in two groups. First group (15 shoulders) was measured it during Boytchev procedure before and after transposition of the conjoined tendon and second group(10 shoulders) was done at one year after the surgery. No recurrence in the second group. Microtip transducer was inserted between the humeral head and the SST. Pressure was measured at two posi-tions: 0, 15, 30, 45, 60 deg of ext. rot. of arm at side and 0, 30, 60, 90 deg of ext. rot. at 90 deg abducted position. (Results) 1 st group:the pressures after the tendon transfer were showed statistical higher than those before the tendon transfer in each degree of two positions. In ext rot. of arm at side, the ave. pressures before the transfer are18, 31, 54, 93, 161 mmhg and the ave. pressures after the transfer are 64, 120, 231, 354, 580mmHg, respectively. In ext rot. at 90 deg abd., the ave. pressures before the transfer are 19, 61, 88, 204mmHg and the ave. pressures after the transfer are 104, 301, 599, 1064 mmhg in respectively. The 2nd group was revealed same levels of the pressure of the ist group after the tendon transfer (not significant). In ext rot of arm at side, the pressures are 40, 107, 193, 273, 451mmHg in respectively. In ext rot. at 90 deg abduction, the pressures are 136, 304, 546, 1018 mmhg, respectively. (Conclusion) 1) Boytchev procedure increases the pressure between the humeral head and the subscapular tendon. 2) This increased pressure was kept at one year after the surgery. 3) Stabilizing mechanism of this procedure is seemed to be this increasing pressure. 133