34TH ANNUAL MEETING OF THE JAPAN SHOULDER SOCIETY

1 F Wave Monitoring After Arthroscopic Shoulder Surgery gers may be used to evaluate the functions of the shoulder joint. It is IWATA Yoshio, Department of Orthopaedics, Uji Takeda Hospital also believed that people can perform approximately half of the ac- MORIHARA Toru, HAYASHIDA Tatsurou, OGURA Akiko, KUBO tions even if the diseased hand is on their dominant side. Toshikazu, Department of Orthopaedics, Kyoto Prefectural Univer- sity of Medicine, Graduate School of Medical Science HORII Motoyuki, Department of Orthopaedic Surgery, Kyoto Inter- 3 The Shoulder Function of Congenital Clavicle Anomalies disciplinary Institute Hospital of Community Medicine KENMOKU Tomonori, Department of Orthopaedics Surgery, Chiba KUROKAWA Masao, Department of Orthopaedic Surgery, Saisei- Univercity Graduate School of Medicine kai Suita Hospital SAISU Takashi, KAMEGAYA Makoto, Division of Orthopaedics Sur- The purpose of this study was to evaluate the modulation of excit- gery, Chiba Children’s Hospital ability of spinal motor neuron function. We investigated F waves af- MIKASA Motohiko, Matsudo Orthopaedic Hospital ter arthroscopic shoulder surgery. We evaluated 7 subjects who There was no report on the shoulder function of congenital clav- underwent an arthroscopic shoulder surgery. There were 5 men icle anomalies. Our purpose was to clarify the role of the clavicle, and 2 women; the mean age at the time of surgery was 33.6 years investigating the shoulder function in patients with clavicle defect old. In our study, F waves were recorded from the abductor pollicis or pseudoarthrosis. muscle after transcutaneous median nerve stimulation at bilateral Thirteen shoulders of 9 patients with congenital clavicle anoma- wrists. Stimulation current was gradually increased to exceed that lies were retrospectively investigated for this study. Diagnoses were needed to evoke a maximum M wave. This supramaximal current congenital pseudoarthrosis in 3 patients, congenital complete de- was used for all subsequent stimulations. Amplification for F wave fect in 1, major defect due to cleidocranial dysplasia in 3, distal de- analysis of 16 consecutive stimuli was delivered. Preoperatively, fect related to congenital progeroid syndrome in 1, proximal half after 1 day, 3 days and 7 days, F waves were recorded. The defect related to Goltz syndrome in 1. The mean follow-up term mean F-wave amplitudes were determined in each time period, was 7 years. We evaluated their range of motion (ROM) of the shoul- and statistical analyses were performed. F wave amplitudes after der and activities of daily living. In a case of congenital defect of the 1 day recorded at each wrist were significantly lower than at pre- clavicle and 2 pediatric cases of cleidocranial dysplasia, slight operation. F wave amplitude gradually increased in time in the post- ROM limitation of the shoulder were seen. In the remaining cases, operative period. However, in case 4, the F wave amplitude was there was no limitation. All patients’ daily activities were not dis- lower than that of preoperation. F wave amplitude can be consid- turbed. In patients with less than a 2/3 defect of the clavicle, there ered a variable reflecting the functional integrity of the motor system was no functional problem of the shoulder. Although mooring mus- from the spinal portion of a motor neuron to the neuromuscular junc- cles of the scapula worked in compensation for the clavicle defect tion. These results suggested that inexcitability of spinal motor neu- in patients with more than a 2/3 defect, they needed to make the ef- ron function is potentially caused by the rest after the operation. F fort to keep not only the elevated position but also the neutral posi- wave monitoring could provide additional information on the state tion of their shoulders. of rehabilitation in the early postoperative period.

4 The Feature of Scapula Malposition with Rotator Cuff Tears 2 Spatial Zones for Activities of Daily Living Centered on KOBAYASHI Hirokazu, KIMIZUKA Kouichiro, Department of Ortho- Shoulder Joints paedic Surgery, Chushin-mastumoto General Hospital HARA Masafumi, Department of Orthopaedic Surgery, Hisatsune HATAYukihiko, Division of Rehabilitation Medicine, Shinshu Univer- Hospital sity School of Medicine TOMINAGA Natsuko, NOMIYAMA Naoko, Hara Baseball Medi- MURAKAMI Narumichi, Sports Medical Center, Aizawa Hospital cal Institute KATO Hiroyuki, Department of Orthopaedic Surgery, Shinshu Uni- Range of motion (ROM) was a functional evaluation of the shoul- versity School of Medicine der joint; yet, there were various methods to evaluate the activities of In the example of rotator cuff tears with a scapula malposition, daily living (ADL) using the upper arms. It was possible to evaluate especially the scapula was often accepted. This study investigated ROM of the shoulder joint and ADL simultaneously. Using spatial the characteristics of the rotator cuff tears with a scapula malposi- zones centered on the shoulder joint, a classification into 6 zones tion. One-hundred consecutive shoulders in 100 patients who under- was performed. Zone 1 for inner lower space, zone 2 for inner up- went rotator cuff repair were studied retrospectively. The age of the per space, zone 3 for exterior lower space, zone 4 for exterior up- patients ranged from 33 to 79 (mean, 62.4) years old and the man per space, zone 5 for lower and rear space, and zone 6 for and woman ratio was the male 57 shoulders and female 43 shoul- upper and rear space. Within each zone, upper arm actions in der. Roentgen-rays of an about the upper arm descent were photo- ADL were classified. (1) ADL items using the upper arm were given graphed to pre-operation, the straight line which connects to 20 adults, and 30 of the more frequent actions were extracted. a scapula socket inferior extremity and the angulus inferior scapula Subsequently, other actions were given, and 100 ADL items ex- with a scapula side image was defined as the scapula length axis, tracted. (2) The 100 ADL items were classified and compared, using and this angle was measured by making the angle with the straight the zone at the humerus and the zone at the hands and fingers. (3) line which connected the surface of the rib of the superior extremity The 100 ADL items were classified into each zone. (4) Actions of the located in that range, and the inferior extremity was the scapula an- dominant hand in ADL were A group, actions executable with 1 gle of inclination. The peak of this angle facing up was the peak of hand were B group, and actions with both hands were C group. a scapula anteversion group and facing down were the scapula ret- The above-mentioned 100 items were classified into respective roversion group. Comparison examinations were performed about groups. (2) When classifying at the humerus, inner /external rota- medical histories, range of motion and the cuff tear size at opera- tion in the shoulder joints was excluded, but when classifying at tion. The range of motion that internal rotation in 2nd position, in the hands and fingers, inner/external rotation was reflected. There- the retroversion group was significantly smaller than that in the ante- fore, it was possible that the classification zone at the hands and fin- version group (P < .05). The size of rotator cuff tear in the

e1 e2 Abstracts J Shoulder Elbow Surg

retroversion group was significantly larger than that in the antever- ally, we performed immunohisotochemical staining of Type Iand III sion group (P < .05).The inclination of a scapula was understood collagen. The coracohumeral ligament overlaid the tendinous por- to be the size of rotator cuff tear was one of the factors. By investigat- tion of the supraspinatus and infraspinatus; however, the coracohum- ing the angle of gradient of a shoulder blade by a shoulder blade eral ligament was distinguished from the tendinous portion of the Roentgen-rays side image showed that it was possible to guess the supraspinatus and infraspinatus by the immunohistochemical stain- size and shoulder joint function of a rotator cuff tear roughly. ing of TypeIcollagen. The tendinous portion of the supraspinatus con- sisted of an anterior thick tendinous portion and a posterior thin fibrous portion. The anterior thick tendinous portion attached to the 5 Can the Abduction Strength Become an Indicator to Express anterior portion of the highest impressions of the greater tuberosity. a Shoulder Function? The tendinous portion of the infraspinatus consisted of a superior thick MIZUNO Naoko, NAKAGAWA Shigeto, Department of Orthopae- tendinous portion and an inferior thin fibrous portion, both of which dic Surgery, Yukioka Hospital were attached to the remaining large portion of the greater tuberos- YONEDA Minoru, YAMADA Shinichi, GOHROKU Takahiro, Shoul- ity. This histological study supported our new anatomical findings. der and Sports medicine service, Osaka Kosei-nenkin Hospital HAYASHIDA Kenji, Department of Orthopaedic Surgery, Osaka Police Hospital 7 Anatomical and Histological Study of the Tendinous and MAE Tatsuo, Department of Orthopaedic Surgery, Kansai Rousai Muscular Structures of the Infraspinatu -Which Layer can be Hospital Delaminated in the Case of the Infraspinatus Tears?- Weakness of abduction strength was often seen in shoulder pa- MOCHIZUKI Tomoyuki, YAMAGUCHI Kumiko, SUGAYA Hiroyuki, tients. The causes were various, such as rotator cuff insufficiency, NAKAGAWATeruhiko, MUNETATakeshi, AKITA Keiichi, 1. Section pain, instability, limited ROM, paralysis and disuse. We hypothe- of Orthopaedic Surgery, Division of Cartilage Regeneration Gradu- sized that abduction strength might reflect a shoulder condition. ate School, Tokyo Medical and Dental University; 2. Funabashi Or- The purpose of this study was to clarify whether abduction strength thopaedic Sports Medicine Center; 3. Unit of Clinical Anatomy, could become an indicator to express a shoulder function. We stud- Graduate School, Tokyo Medical and Dental University; 4. Depart- ied 57 patients (38 males and 19 females) with shoulder disorders. ment of Orthopaedic Surgery, Douai Memorial Hospital; 5. Section The average age was 36 years old. Twenty-five shoulders had ante- of Orthopedic Surgery, Graduate School, Tokyo Medical and rior instability, 21 shoulders had rotator cuff tear, 5 shoulders had Dental University throwing injury and 6 had other problems. Preoperative isometric The purpose of this study was to estimate the pathology of the de- abduction strength was measured at 90 degree abduction with lamination in the infraspinatus tear by the anatomical and histolog- a hand-held dynamometer (MicroFET). We calculated the ratio be- ical study of normal specimens. tween the strength of the affected shoulder and the non-affected Twenty-seven shoulders of 15 cadavers were used for this study. shoulder. As the methods for evaluating the shoulder function, we Seventeen specimens were observed macroscopically. The rest of the used the Japanese Orthopaedic Association scoring system for 10 specimens were used for histological sections and were investi- shoulder disorders (JOA score), The American Shoulder and Elbow gated histologically especially around the humeral insertion of the in- Surgeons shoulder evaluation form (ASES), Constant score and Sim- fraspinatus. The transverse muscular portion from the inferior surface ple Shoulder Test (SST). We analyzed correlations between abduc- of the spine and oblique muscular portion from the infraspinatous tion strength and the score of each evaluation method using fossa merged into the tendinous portion and inserted to the greater Pearson’s correlation coefficient. The average ratio of abduction tuberosity. The oblique muscular portion contained most of the tendi- strength was 0.711 (0-1.16). According to the average scores of nous portion of the infraspinatus. On the other hand, the transverse evaluation methods, JOA score was 72.1, ASES 58.9, Constant muscular portion had almost no tendinous tissues but aponeurosis score 70.8 and SST 7.6. The correlation coefficients between abduc- macroscopically and histologically. The tendinous portion of the in- tion strength and the scores were as follows: JOA score 0.716, ASES fraspinatus was a dense layered structure; however, the diffusible 0.712, Constant score 0.810 and SST 0.744. There were signifi- gap could be observed in that layered structure of the tendinous por- cant correlations between abduction strength and the scores (P < tion of the infraspinatus in all specimens. This study suggested that the .0001). The results of this study have shown that there were strong delamination in the infraspinatus tear may occur not between the significant correlations between abduction strength and the scores transverse and oblique muscular portion, but in the layered structure of evaluation methods. It suggested abduction strength could of the tendinous portion from the transverse muscular portion. become an indicator to express a shoulder function. 8 Superficial Fibers from the Supraspinatus Tendon to the 6 Histological Study of the New Footprint of the Infraspinatus Tendon. Supraspinatus and Infraspinatus YOSHIMURA Hideya, MOCHIZUKI Tomoyuki, NIMURA Akimoto, MOCHIZUKI Tomoyuki, YAMAGUCHI Kumiko, ARAI Ryuzou, ARAI Ryuuzo, SUGAYA Hiroyuki, MUNETA Takeshi, AKITA Keiichi, YOSHIMURA Hideya, SUGAYA Hiroyuki, AKITA Keiichi, Section Division of Orthopedic Surgery, Oume Municipal General Hospital; of Orthopedic Surgery, Division of Cartilage Regeneration Gradu- Section of Cartilage Regeneration, Graduate School, Tokyo Medi- ate School, Tokyo Medical and Dental University; Unit of Clinical cal and Dental University; Funabashi Orthopaedic Sports Medicine Anatomy, Graduate School, Tokyo Medical and Dental University; Center; Section of Orthopedic Surgery, Graduate School, Tokyo Funabashi Orthopedic Sports Medicine Center; Division of Ortho- Medical and Dental University; Unit of Clinical Anatomy, Graduate pedics Oume Municipal General Hospital School, Tokyo Medical and Dental University We reported on new footprints of the supraspinatus and infraspi- In the process of investigating the structure of the rotator cuff, the natus, which represented that humeral insertion of the supraspinatus superficial fibers, which originated from the supraspinatus tendon was localized in the anteromedial portion of the highest impression of and ran to the greater tuberosity beyond the infrasupinatus tendon, the greater tuberosity and the insertion of the infraspinatus extended were observed in many specimens without rotator cuff tear. On the to the large portion of the greater tuberosity. The purpose of this study other hand, in the specimens with rotator cuff tears, thicker fibrous was to investigate tendinous insertion on the greater tuberosity by mi- bundles, running from the supraspinatus to the posterior portion of croscopic examination using histological sections. Seven specimens the greater tuberosity along the posterior margin of the torn area, of 4 cadavers were used in this study. One specimen with degenera- were observed. Thus we suspected that the superficial fibers from tive cuff tear was excluded. We prepared histological sections that the supraspinatus prevent the posterior enlargement of the torn lesion contained humeral attachment sites and stained these with hematox- and investigated the frequency and pattern of the superficial fibers. ylin and eosin, Masson trichrome and Elastica van Gieson. Addition- Eighty-two shoulders of 41 adult cadavers were used in the present J Shoulder Elbow Surg Abstracts e3

study. After resection of the acromion, we removed the coracohum- evaluate the biomechanical property, tensile testing was performed eral ligament meticulously. In 70 specimens without rotator cuff tears, using a material testing machine AUTOGRAPH AG-ITM. The speci- we researched the frequency and pattern of the superficial fibers of mens were loaded to failure at the rate of 1mm/s. The structural prop- the supraspinatus tendon. In 12 specimens with rotator cuff tears, erties of linear stiffness, yield load, and ultimate load were calculated we investigated the relationship between the torn lesion and the su- using software TRAPEZIUMTM. The geometric properties were as fol- perficial fibers. In 62 of 70 specimens without rotator cuff tear, the su- lows: the mean thickness of the infraspinatus tendon, 5.9 6 1.6 mm; perficial fibers from the supraspinatus tendon running from the tendon the mean size of the footprint, 25.9 6 4.5 mm in the anterior?poste- proper to the greater tuberosity were seen. There were various pat- rior direction, 13.8 6 1.7 mm in the medial?lateral direction. The bio- terns of attachments to the infrasupinatus tendon in those superficial mechanical properties of the infraspinatus tendon were as follows: fibers. In 7 specimens, those had a torn lesion located at the anterior yield load, 643.1 6 200.6 N; ultimate load, 868.7 6 190.1 N; lin- portion of the greater tuberosity, the thick superficial fibrous bundle ear stiffness, 136.0 6 44.6 N/mm. According to previous cadaveric was observed on the posterior margin of the torn lesion. In the rest, studies using human shoulders, the thickness of the supraspinatus ten- 5 specimens with a large or massive tear, we could not find the similar don was 5.8 mm, the footprint was 16.3 mm to 25 mm in anterior?- fibrous bundles on the posterior margin of the torn area. These results posterior direction and 12.3 mm to 12.7 mm in medial?lateral. The suggest that the superficial fibers from the supraspinatus tendon might ultimate load of supraspinatus tendon ranged from 652 N (average prevent the posterior enlargement of the rotator cuff tears. age, 64 years old) to 1007 N (average age, 55 years old). The geo- metric and biomechanical properties of the porcine infraspinatus were similar to those of the human supraspinatus tendon. Therefore, 9 Stabilization System of the Long Head of the Biceps Tendon the porcine infraspinatus tendon can be used for the biomechanical ARAI Ryuzo, SUGAYA Hiroyuki, MORIISHI Jyoji, Funabashi Ortho- testing to evaluate the rotator cuff repair techniques. paedic Sports Medicine Center MOCHIZUKI Tomoyuki, Section of Cartilage Regeneration, Tokyo Medical and Dental University Graduate School 11 Behavior of Graft and Host Cells after Transplantation of YAMAGUCHI Kumiko, AKITA Keiichi, Unit of Clinical Anatomy, Frozen or not Achilles Tendon for a Rotator Cuff Defect Tokyo Medical and Dental University Graduate School TACHIIRI Hisakazu, Department of Orthopaedics, Social Insurance The long head of the biceps tendon (LHB) tended to dislocate an- Kyoto Hospital teromedially due to its change of direction beyond the most proximal MORIHARAToru, IWATAYoshio, KIDAYoshikazu, KUBO Toshikazu, portion of the intertubercular groove. The purpose of this study was to Department of Orthopaedics, Graduate School of Medical Science. clarify the comprehensive stabilization system of the LHB by investi- Kyoto Prefectural University of Medicine gating the most proximal insertion of the subscapularis tendon KUROKAWA Masao, Department of Orthopaedics, Saiseikai Suita (SSC), the superior glenohumeral ligament (SGHL) and the coraco- Hospital humeral ligament (CHL). Twenty embalmed shoulder girdles were The purpose of this study was to examine the behavior of the host used in an anatomical study, and in order to clarify the structural con- and graft cells in early remodeling process after tendon implantation tinuity, 5 anterosuperior parts of the glenohumeral joint were histo- to the defect using a green fluorescent protein (GFP) transgenic rat. logically observed. Anatomically, the most proximal portion of the Sprague Dawley (SD) rats and GFP rats were used in this study. Ten- SSC tendon inserted on the superior surface of the lesser tuberosity dinous defect were made close to the supraspinatus tendon insertion. and extended a thin tendinous slip to the fovea capitis of the humerus. In group A, Achilles tendons of SD rats were transplanted into the de- The SGHL was like an anterior-inferior spiral sling supporting the LHB fect of GFP rats. In group B, frozen Achilles tendons of SD rats were and attached to the tendinous slip. Histologically, the CHL and inter- transplanted into the defect of GFP rats. At 0, 3 and 7 days after sur- nal wall of the anterosuperior glenohumeral joint were involved in the gery, sections stained with hematoxylin and eosin were assessed his- identical loose connective tissue. The SGHL was discriminated from it tologically, and localization of GFP positive cells were also due to density of tissue fibers at the lateral part, but the difference be- evaluated. Frozen Achilles tendons of GFP rats were also assessed. tween them was unclear in the medial part. The SGHL was consid- No cells were observed in the frozen Achilles tendons. The graft ered to be a fold extended from the medial part of anterosuperior was surrounded by inflammatory cells at 3 days. Signal positive loose connective tissue and formed a spiral half sling along the host cells were observed in the peripheral margins in group A at 3 LHB. The most lateral part of the loose connective tissue wound days. There were no GFP cells in the graft substance. At 7 days, acel- around the SGHL to form a membranous structure to support the lular areas remained in the core part of the graft in group B. GFP cells LHB, which attached to the thin tendinous slip of the SSC. These re- in group B were less infiltrated into graft than in group A. Replace- sults suggested that the full thickness and articular side SSC tear might ment of graft cells by host cells occurred in the early remodeling pro- lead to loss of the LHB support because of disruption of both the semi- cess after tendon implantation for the defect of rotator cuff. GFP host tubular structure which consisted of the most proximal insertion of the cell infiltrated the graft in a frozen Achilles tendon later than that in SSC and the tendinous slip and the membranous structure of the loose a live Achilles tendon. It is considered that the live graft cells were im- connective tissue including the SGHL and CHL. portant for the repair and the remodeling of the graft.

10 Biomechanical Propaties of Porcine Infraspinatus Tendon 12 Biomechanical Comparison of Contact Area and Contact FUKUHARA Tetsutaro, MIHATA Teruhisa, HORINOUCHI Takashi, Pressure for the Rotator Cuff Repair with Absorbable Knotless YASUI Kenji, ASAI Shigehiro, WATANABE Chisato, KINOSHITA Suture Anchors Mitsuo, Osaka Medical College NAKAMICHI Noriaki, MATSUMURA Noboru, SHIONO Shohei, Arthroscopic rotator cuff repair has become increasingly popu- TANJI Atsushi, NAGURA Takeo, NAKAMURA Toshiyasu, TOYAMA lar. There have been several procedure related studies using human Yoshiaki, IKEGAMI Hiroyasu, Department of Orthopaedic Surgery, cadaveric shoulders. In some studies, animal shoulders have been Keio University used as the consistency of their tissue. To our knowledge, there has The contact area and contact pressure at the tendon-bone area in- been only one biomechanical study using porcine shoulders. How- terface after the rotator cuff repair have not been investigated. To ever, the properties of the tendon were not examined in the study. compare the contact area and contact pressure of different types of The objective of this study was to know the biomechanical properties suture anchors for a rotator cuff tear repair. Two types of absorbable of the porcine infraspinatus tendon. suture anchors, Panalok loop rc PL Group, Bioknotless rc BK Group Five fresh frozen porcine shoulders (6 months old) were dissected, were inserted into the urethane made blocks. Anchors were inserted while the infraspinatus tendons were left intact. The thickness of the in- perpendicular to the block surface. The contact area and contact fraspinatus tendons and the size of the footprints were measured. To pressure were recorded. The contact area of the BK group was e4 Abstracts J Shoulder Elbow Surg

56% greater than that of the PL group. The contact pressure of the BK The purpose of this study was to investigate the usefulness of preop- group was 72% greater than that of the PL group. The Bioknotless rc erative evaluation by ultrasonography (US) of rotator cuff tears (RCT). anchor may provide a better healing than the Panalok loop rc anchor. Twenty-three shoulders in 23 cases with rotator cuff tears were examined using 7.5-13 MHz linear phased transducer in both the long and short axial plane. The ultrasonic surface contour of the rotator cuff tendon in 13 Epidemiology of Asymptomatic Rotator Cuff Tears the long axial plane was classified into convex, flat, concave and defec- NAKAJIMA Daisuke, YAMAMOTO Atsushi, OSAWA Toshihisa, tive. We defined the size of RCT measured using US (the US size of RCT) KOBAYASHI Tsutomu, SHITARA Hitoshi, TAKAGISHI Kenji, De- was the product of width of RCT in the long axial plane by that in the short partment of Orthopaedic Surgery, Gunma University Graduate axial plane. We compared the ultrasonic surface contour and the US School of Medicine size of RCTwith the arthroscopic findings according to the classifications Rotator cuff tear was one of the typical diseases causing pain in of Deorio and Cofield. In the arthroscopic findings, there were 4 bursal- the shoulder joint, but it is also known that asymptomatic rotator side incomplete tears, 2 articular-side incomplete tears, 8 small tears, 5 cuff tear occured with aging. This study investigated the clinical epi- medium tears and 4 large tears. It was difficult to predict the arthroscopic demiology of asymptomatic rotator cuff tears. Local medical exami- findings from the ultrasonic surface contour of the rotator cuff tendon in nations were given to 5,660 residents of a village. Of these, 683 the long axial plane, especially when the surface was flat or concave. people (1,366 shoulders) were included in this study. The subjects In the US size of RCT, there were significant differences between a large 6 2 6 2 were 229 males and 454 females with an average age of 57.9 years tear (258 70 mm )andamediumtear(168 33 mm )orasmalltear 6 2 < old (range, 22~87 years). Background data were collected by ques- (102 35 mm ) in the arthroscopic findings (P .05). We proposed tionnaire including sex, dominant hand, occupation, presence of a new diagnostic criteria that included 2 factors, the ultrasonic surface contour and the US size of RCT. In the criteria, a small rotator cuff tear shoulder joint pain, and the presence or absence of rotator cuff 2 tear was determined by ultrasonography. We classified the subjects was diagnosed with less than 150 mm , a medium tear was more than 150 mm2 and less than 250 mm2 and a large tear was more into the following 3 groups, symptomatic cuff tear group, asymptom- 2 atic cuff tear group, and no tear group, and compared the findings of than 250 mm in the US size of RCT. In 22 out of 23 cases in this study, the 3 groups. Rotator cuff tear was demonstrated in 283 shoulders the diagnosis by the criteria corresponded to the arthroscopic findings. (total 20.7%) and 185 shoulders (total 13.5%) were asymptomatic. Fifty-five shoulders (29.7%) of subjects with asymptomatic rotator cuff 16 CT Arthrography for the Diagnosis of Rotator Cuff Tears tears had previously noticed shoulder pain. The frequency of both FUKUTA Shoji, NISHIYAMA Takeshi, DOI Hideyuki, OHMORI symptomatic and asymptomatic tears tended to rise with age. There Takao, Department of Orthopaedic Surgery, Kochi Health Sciences was no difference between each group in age, sex or dominant Center hand. Although the frequency of rotator cuff tear was high in the It was important to evaluate the preoperative state of a torn rota- heavy worker compared with the light worker, the difference be- tor cuff to perform a successful arthroscopic rotator cuff repair. The tween symptomatic and asymptomatic was not recognized. purpose of this study was to determine the usefulness of CT arthrog- raphy (CTA) for diagnosing rotator cuff tears (RCT). Eighty-seven shoulders from 87 patients who had undergone both magnetic res- 14 Factors affecting the Aging and Tearing of the onance imaging (MRI) and CTA preoperatively and subsequent ar- Supraspinatus Tendons by Consequtive MRIs throscopy were included in this study. There were 52 men and 35 YAMANAKA Kaoru, Yamanaka Orthopaedic Clinic women. The average age of the patients was 63.4 years old, with HAMADA Kazutoshi, Department of Orthopaedics Shizuoka Red a range of 17 to 82 years old. Images of CTA were reconstructed Cross Hospital in the oblique-sagittal and oblique-coronal planes same as MRI. Thirty-seven shoulders (36 patients) more than 40 years old without The presence and size of RCT were evaluated separately and these apparent complete supraspinatus tendon tear were studied by serial results were compared with arthroscopic findings. In CTAs, there MRIs to evaluate the factors affecting the aging and tering the supraspi- were 55 shoulders diagnosed as RCT. There were 16 small tears natus tendons. There are 13 males and 23 females with the averaged (less than 1 cm), 17 medium-sized tears (1 to 3 cm), 16 large tears age of 62 years old. The mean period between the initial and the final (3 to 5 cm), and 6 massive tears (more than 5 cm). The presence and MRIs was 14.6 months and disease periods was 6.1 months. size of RCT in CTAs was approximately matched to our arthroscopic The MR images of supraspinatus, infraspinatus and subscapularlis findings. MRIs could not detect a complete tear in 15 of 18 small tendons were assessed bysignal intensity in the tendon. Signal intensity tears diagnosed in CTA. In RCT with a size of larger than 1 cm, find- of the tendon was classified into 6 grades. Grade 0: tendon was occu- ings of MRI and CTA were similar. CTA had a sensitivity of 100%, pied with low signal intensity area. Grade 1: iso signal intensity area a specificity of 90.6% and an accuracy of 96.6% for the diagnosis was scattered in the tendon. Grade 2: high signal intensity area was of tears of the supraspinatus. The sensitivity, specificity, and accuracy scattered in the tendon. Grade 3: high signal intensity area was mainly of MRI was 75.8%, 96.6%, 82.8%, respectively. CTA is useful in eval- in the bursal side of the tendon. Grade 4: high signal intensity area was uating RCT and more sensitive than MRI for detecting a small tear. mainly in the middle of the tendon. Grade 5: high signal intensity area was mainly in the joint side of the tendon. High signal intensity in the bursa (subacromial, subscapularis bursa and bicipital sheeth) and joint (glenohumeral and acromio clavicular) was classified into 3 grades, 17 Relationship between Superior Migration of the Humeral namely, grade 0: none; grade 1: mild; grade 2: apparent. Increase Head and the Size of Torn Tendons on Massive Rotator Cuff of high signal intensity area in the SSP tendon was seen in 16 cases Tear and decrease of high signal intensity area was seen in 15 cases at NAMURA Takehiko, Department of Orthopaedic Surgery, Matsush- 2nd MRI. Six cases remained in the same grade. 2 shoulders pro- ita Memorial Hospital gressed to complete cuff tear. High signal intensity in the glenohumeral MORIHARA Toru, TAKUBO Yoshinori, HIRATA Masazumi, IWATA joint, subacromial bursa and bicipital groove may predispose the Yoshio, OGURA Akiko, HORII Motoyuki, KUBO Toshikazu, Depart- supraspinatus tendon to increase of the high signal intensity area. ment of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine KUROKAWA Masao, Department of Orthopaedic Surgery, Saisei- 15 Preoperative Evaluation by Ultrasonography of Rotator kai Suita Hospital Cuff Tears The aim of this study was to clarify the relationship between supe- NAKAI Daisuke, SUZUKI Eiichi, Department of Orthopaedic Sur- rior migration of the humeral head and torn tendon on massive rota- gery, Sagamihara Kyodo Hospital tor cuff tear. We studied 23 shoulders in 17 patients of massive J Shoulder Elbow Surg Abstracts e5

rotator cuff tear seen from April 2004 to March 2007 in our hospital. JOA pain score at follow-up showed 15.0 6 5.4 points significantly There were 15 men and 2 women, their mean age was 70.5 years higher than 8.263.1 points before injections. The ratio of shoulders old (range, 56-81 years), right-side 16 shoulders and left-side 7 which showed a pronounced effect or improvement (good effects) at shoulders. We evaluated the superior migration of the humeral follow-up was 49?. The shoulders with small tears showed good ef- head by x-rays on the supine and standing position, and torn tendon fects after injections of steroids compared with those with large tears. size by MRI. We evaluated whether rupture of the long head of the The JOA pain score at follow-up in groups A and C with a narrowed biceps tendon (LHB) led to the superior migration of the humeral joint space was lower than that of other groups and all shoulders in head. On x-rays, superior migration of the humeral head were recog- group A showed a relapse. The shoulders with large amounts of sub- nized in 7 shoulders in both the supine and standing positions, 13 acromial effusions showed good effects after their 1st injection com- shoulders were so only in the supine position. Three shoulders pared with those with small effusions. The evaluation and expectancy were recognized neither in the supine nor standing position. On of the effects of subacromial injections of steroids for rotator cuff tears MRI, all 7 shoulders showed superior migration in the standing posi- using x-ray findings and MRI is useful in the choice of a therapy. tion recognized complete tears in supraspinatus, infraspinatus and subscapularis tendon, and 19 of 20 shoulders in the supine position recognized rupture of the LHB tendon. In massive rotator cuff tear, the 20 Classification of Full-thickness Tears of the Subscapularis superior migration in the supine position will take place if the LHB ten- IDE Junji, TOKIYOSHI Akinari, HIROSE Jun, MIZUTA Hiroshi, don is ruptured, and thus further the superior migration in the stand- Department of Orthopaedic and Neuro-Musculoskeletal Surgery, ing position will take place if the infraspinatus and subscapularis are Faculty of Medical and Pharmaceutical Sciences, Kumamoto Univer- torn completely, because the depressor for the humeral head is lost. sity, Department of Orthopaedic Surgery, Kumamoto University Hospital 18 The Effects of Conservative Treatment for Full-thickness Full-thickness tears of the subscapularis were classified by tear Rotator Cuff Tears - 2nd Report size and tendon retraction at arthroscopic evaluation. 20 consecu- tive patients (20 shoulders) with traumatic anterosuperior rotator MAKIUCHI Daisuke, SUZUKI Kazuhide, MIHARA Kenichi, MATSU- cuff tear were evaluated in this study. There were 17 men and HISA Takayuki, NISHINAKA Naoya, YAMAGUCHI Ken, TSUTSUI 3 women; their mean age was 61.7 years (range, 44-79 years). Hiroaki, Department of Orthopaedic Surgery, Showa University When the superior 1/3 (superior 1/2 of tendon portion) of the attach- Fujigaoka Rehabilitation Hospital ment was torn, the tear size was classified as grade 1 (n ¼ 5), when The aim of this study was to investigate the clinical outcome of con- the superior 2/3 (all tendon portion) of the attachment was involved, servative treatment for full-thickness rotator cuff tears (FTRCTs), and to the classification was grade 2 (n ¼ 15), when all (tendon and muscu- analyze factors that influence the clinical outcome. Weselected 19 pa- lar portion) of the attachment was torn, as grade 3 (n ¼ 0). When the tients who were diagnosed as having FTRCTs by MRI or MR arthrogra- tear edge was over the lateral articular cartilage margin at neutral ro- phy and were treated conservatively, and were followed-up for more tation, tendon retraction was classified as minimal (n ¼ 2), when in an than 2 years. There were 7 males and 12 females with an average age area lateral to the glenoid surface, as moderate (n ¼ 8), and when on of 66.4 years old. All patients were evaluated with the use of the JOA the glenoid surface level or in an area medial to the glenoid surface, score, and we investigated the transition of each score. The mean JOA as severe (n ¼10). Larger tear had more severe tendon retraction. score improved from 58.3 at the initial examination to 85.4 at the last The inferior muscular portion of the subscapularis was retained in examination. The mean range of external rotation improved from all patients. As viewed from the anterosuperior portal, the attachment 46.32 at the time of initial examination to 59.21 at the last examina- of the inferior muscular portion of the subscapularis to the humerus tion. The mean range of active flexion improved from 86.05 at the was detected as a guide to find the torn subscapularis tendon. The in- time of initial examination to 152.11 at the last examination. The cidence of recurrent tears was significantly higher in patients with se- function score and ROM score revealed good improvement in all pa- vere (6 of 10 patients) in comparison to minimal or moderate tendon tients. The pain score also revealed good improvement in the excellent retractions (1 of 10 patients) (P ¼.0191). group; but in the poor group, the pain score revealed few improve- ments between the initial and the last follow-up examination. Our clin- ical results of conservative treatments for the patients with FTRCTs were almost satisfactory.For the improvementof the function and ROM, con- 21 Clinical Outcome of Arthroscopic Repair for Subscapularis servative treatments were effective. However, the conservative treat- Tendon Tear ment was insufficient for the patients who reported few KIKUGAWA Kazuhiko, OKUHIRA Nobuyoshi, Department of improvements of pain in the early stage of treatments. Orthopaedic Surgery, Mazda Hospital Few studies have been evaluated the arthroscopical repair for subscapularis tendon tear. The purpose of this study was to evaluate 19 Clinical Effects of Subacromial Injections of Steroids for the clinical outcome of arthroscopic repair for subscapularis tendon Rotator Cuff Tears with Various Image Findings tear. We treated 137 rotator cuff repairs from 2003 to 2007. Among TAKAHASHI Akira, NAKAJIMA Kuniharu, MATSUMOTO Risa, FU- them, 15 shoulders with subscapularis tendon tears were treated by KUMURA Hidenobu, SAITO Tomoyuki, Department of Orthopaedic arthroscopic repair, 12 shoulders were assessed. The cases were 8 Surgery, Yokohama City University males and 4 females, with an average age of 62 years old. The Clinical effects of subacromial injections of triamcinolone for 53 mean follow-up period was 16 months. Three cases were subscapu- shoulders with rotator cuff tears were investigated and compared laris tendon tears only, 6 cases were concomitant supraspinatous with the x-ray findings, the amount of subacromial effusions and tears, and 3 cases were concomitant supraspinatous and infraspina- the cuff tear size. The x-ray findings were classified into 5 groups? tous tears. Ten cases were repaired using suture anchors and 2 cases group A, superiorly migrated humeral head and narrowed joint were repaired using side to side stiches. The clinical evaluation was space in 4 shoulders? B, only superior migration in 8? C, only nar- performed using the JOA score, lift-off test and berry-press test. The rowed joint space in 2? D, no changes in 20? E, only subacromial range of motion and muscle strength were evaluated by Cybex. spurs more than 5 mm in 19. The cuff tear size was examined by op- The average postoperative JOA score increased significantly from erative findings or MRIs and the amount of subacromial effusions was 52 points to 91 points. The clinical results were excellent in 6 cases, classified by MRIs into 4 groups? none?small?medium and large. good in 3, fair in 2, poor in 1. Preoperatively, the lift-off test was pos- The effects of steroids were classified by the motion and night pain itive in 8 shoulders and the berry-press test was positive in 11 shoul- into 5 grades? pronounced effect, improvement, slight improvement, ders. Postoperatively, the lift-off test was positive in 1 shoulder and the relapse and no change. The effects after a 1st injection and at follow- berry-press test was positive in 1 shoulder. The clinical outcome of ar- up, JOA pain scores and the final outcomes were investigated. The throscopic repair for subscapularis tendon tear was satisfactory. e6 Abstracts J Shoulder Elbow Surg

22 Comparison of Arthroscopic Repair using Single-Row 24 Second-look Evaluation Post Arthroscopic Rotator Cuff Technique for Bursal Side Partial-Thickness Rotator Cuff Tear Repair-Assessment of the Surgical Procedure in the Group with and Full-thickness Rotator Cuff Tear Postoperative Good Clinical Results HORIGOME Keiko, Department of Orthopaedic Surgery, Asahi- MANAKA Tomoya, ITO Yoichi, NAKAO Yoshihiro, NAKA Yoshi- kawa Kosei Hospital fumi, NAKAMURA Nobuyuki, TOMO Hiroyasu, MATSUMOTO The present study was designed to evaluate the efficacy of our Isshin, SAKAGUCHI Kimikazu, TAKAOKA Kunio, Department of arthroscopic repairing procedure for bursal side partial-thickness ro- Orthopaedic Surgery, Osaka City University Graduate School of tator cuff tear, where only the torn cuff was debrided and sutured Medicine without converting to a full- thickness tear to the humeral head with Arthroscopic rotator cuff repair was developed with advances in single-row anchor(s). Because the articular footprint of bursal side arthroscopic techniques and used successfully to treat rotator cuff partial-thickness rotator cuff tear was intact. We compared the clin- tears. However, there was little known about postoperative accurate ical results with those of arthroscopic single-row repair for full-thick- second look evaluation for arthroscopic rotator cuff repair. The aim ness rotator cuff. Partial-thickness tear types of Ellman’s type B2 and of this study was to evaluate the current arthroscopic rotator cuff re- B3 were indicative of this procedure. These patients (partial tear pair technique by second look arthroscopy in the cases of good clin- group: PTG) and those with full-thickness tear treated with single- ical results. We evaluated 11 patients (8 males and 3 females) who row fixation (full-thickness tear group: FTG) were followed up for had undergone arthroscopic rotator cuff repair for full-thickness rota- more than 12 months postoperatively and analyzed. There were tor cuff tears. The average age of the time of the surgery was 61.5 15 patients (16 shoulders) in PTG and 16 patients (17 shoulders) years old (range, 49-70 years). The second look evaluation was in FTG. The average age was 57.7 years old in PTG and 62.1 years composed of 6 different items: hypertrophy of intra-articular syno- old in FTG. At operation time, the Japanese Orthopaedic Associa- vial tissue, articular side integrity at the repaired rotator cuff, hyper- tion score (JOA score), strength of shoulder abduction and external trophy of intra-bursal synovial tissue, bursal side integrity at the rotation were measured and compared between these 2 groups at 6 repaired rotator cuff, bursal tissue adhesion, and appearance of cor- and 12 months postoperatively. We also evaluated the postopera- aco-acromial arch. Full-thickness tear was observed in 2 cases and tive MRIs. The average operation time was 154 min in PTG and partial-thickness tear was observed in 5. Complete rotator cuff re- 162 min in FTG. The average JOA score improved from 71.3 to pair was seen only in 4 cases. Four cases of hypertrophy of intra-ar- 90.3 at 6 months and 97.4 at 12 months in PTG, while it did from ticular synovial tissue, 4 cases of hypertrophy of intra-bursal synovial 66.5 to 89.2 and 95.1 in FTG. The average strength of shoulder ab- tissue, 7 cases of bursal tissue adhesion, and 10 cases of newly duction and external rotation increased from 4.5 kg to 4.8 kg and formed coraco-acromial ligaments were recognized. Bursal tissue 6.3 kg and from 5.6 kg to 7.6 kg and 9.2 kg, respectively, in adhesion and remained rotator cuff tear might be one of the prob- PTG. They increased from 2.8 kg to and 4.8 kg and 6.3 kg and lems of current arthroscopic rotator cuff repair technique. from 4.2 kg to 7.1 kg and 8.3 kg, respectively, in FTG. There were no statistical differences between the groups. Postoperative MRIs did not show any re-torn cuff in both either groups. This tech- 25 Post-operative Change of Thickness of Infraspinatus nique is relatively simple and fairly applicable to PTG. Measured by Ultrasonography ISHITANI Eiichi, Morooka Orthopaedic Hospital MATSUURA Koumei, Department of Orthopaedic Surgery, Kita- 23 Clinical Trial with New Double Row Fixation using Suture kyushu Municipal Wakamatsu Hospital Reel Technique for Arthroscopic Rotator Cuff Repair We reported that the cross-sectional area (CSA) by MRI did not MORIHARA Toru, IWATA Yoshio, TAKUBO Yoshinori, TACHIIRI show any significant recovery until postoperative 1 year; however, Hisakazu, OGURA Akiko, KIDA Yoshikazu, KUBO Toshikazu, the muscle strength of shoulder showed significant recovery after the Department of Orthopaedics, Graduate School of Medical Science, operation. In this study, we evaluated the changes of thickness of the Kyoto Prefectural University of Medicine infraspinatus (ISP) by ultrasonography after arthroscopic rotator cuff HIRATA Masazumi, KUROKAWA Masao, Department of Orthopae- repair and investigated the differences with CSA and the differences dic Surgery, Saiseikai Suita Hospital of thickness between static state (at rest) and dynamic state (active). HORII Motoyuki, Department of Orthopaedics, Kyoto Interdisciplin- We investigated 27 cases (16 males and 11 females) that had ary Institute Hospital of Community Medicine ultrasonography and MRI before operation, 6 months and 1 year af- Arthroscopic rotator cuff repair was carried out with suture an- ter the operation. The mean age at operation was 60.9 years old chors. The dual row fixation has been popular instead of the single (48–78). The thickness of bi-lateral sides was measured by ultraso- row fixation. We developed a new double row fixation using suture nography at rest and active. The point of the measurement was me- reel technique. In this study, we introduce the technique and the char- dial 1/4 and 3 cm inferior from the scapula’s spine. We measured acteristics. First, an anchor was inserted in the proximal side of the CSA in the inside 1 cm part from the joint with an MRI oblique- greater tuberosity and mattress sutures were performed. Then, 2 an- sagittal T2 image. Changing in thickness on the affected side: it chors were inserted in the distal side of the greater tuberosity. Single changed from 11.1 mm to 11.3 mm to 11.7 mm at rest. It changed suture was passed through the cuff. After making the suture and one from 13.2 mm to 13.9 mm to 14.5 mm on active. The thickness at end of the fastened suture in the mattress suture together as post rest did not show a meaningful change, but showed a statistically sig- strand, we tied a sliding knot (suture reel technique). In vitro study us- nificant increase at both postoperative 6 months and 1 year. Chang- ing a bone model, the pressure and area of contact were compared ing of CSA: it changed from 4.76 cm2 to 4.49 cm2 to 4.57 cm2.We among a single row fixation, dual row fixation and our new dual row showed a significant decrease in the postoperative 6 months. fixation. We performed clinically this procedure on 6 shoulders in 6 ISP muscle volumes of static state (the thickness of ISP at rest and patients with medium rotator cuff tear seen from January 2007 to CSA) did not increase, but its dynamic state (the thickness of ISP on March 2007 in our hospitals. There were 4 men and 2 women, the active) increased significantly. We thought that the muscular fiber’s mean age 63 years old (range, 54-73 years old). We evaluated volume increased to respond to recovery of a nervous factor. The the troubles during the surgery and the short term clinical results. measurement of thickness of dynamic state is a very useful method (Results) In vitro study, the size of the contact area in our new fix- to evaluate the recovery of a muscle after an operation. ation was significantly larger than the other single and dual row fix- ations. There were no significant differences of pressure on the contact area among them. In all 6 cases, there was no trouble during 26 MRI Evaluation of Arthroscopic Double Row Rotator Cuff the surgery. Our new double row fixation using the suture reel tech- Repairs for Delamination Type Tears nique is considered to be one of the useful methods for arthroscopic SAKAGUCHI Kimikazu, ITO Yoichi, NAKA Yoshifumi, NAKAO rotator cuff repair. Yoshihiro, MANAKA Tomoya, NAKAMURA Nobuyuki, TOMO J Shoulder Elbow Surg Abstracts e7

Hiroyasu, MATSUMOTO Isshin, TAKAOKA Kunio, Department of We classified them in 2 groups: the re-tear group after operation and Orthopaedic Surgery, Osaka City University Graduate School of the non-re-tear group, and evaluated the preoperative tear shape, at- Medicine rophy of rotator cuff muscle belly, fat degeneration using MRIs. The Delamination was one of the horizontal tears combined with ar- fat degeneration was evaluated by Goutllier’s classification. Further- ticular side tears and bursal side tears observed in full-thickness rota- more, we investigated tbe postoperative changes at a later period. tor cuff tears. Double row rotator cuff repair was a current surgical We diagnosed re-tear in 6 shoulders (15%) out of 40 shoulders in technique for rotator cuff tears with delamination. The aim of this MRIs at a postoperative 6 months. The tear size had a tendency of en- study was to evaluate the usefulness of double row repair technique largement. The age of either group did not have a significant differ- for delamination by MRI. We evaluated retrospectively 18 patients ence. Preoperative rotator cuff tear size of the re-tear group was in which we performed arthroscopic double row repair for delami- larger than of the non-re-tear group in transverse and longitudinal di- nation. Postoperative MRI was performed at 8.6 months on aver- ameters, significantly (P <.01). The small tendency had the cross-sec- age. MRI findings were classified according to the modified tion product of rotator cuff belly of muscle in re-tear group, but there Sugaya’s classification (Type1, sufficient thickness with homoge- was not the statistical significance difference. As a risk factor of a re- nously low intensity; type 2, sufficient thickness with partial high in- tear, it was thought that a preoperative rotator cuff tear being big, tensity; type 3a, articular side re-tear; type 3b, bursal side re-tear; fatty degeneration of rotator cuff belly of muscle were strong. We type 4, presence of a minor discontinuity; type 5, presence of a ma- conclude that the risk factors of rotator cuff re-tear are preoperative jor discontinuity). Postoperative MRIs revealed 6 type 1 (33.3%), 3 large tear, fat degeneration of the muscle belly. type 2 (16.7%), 6 type 3a (33.3%), 0 type 3b (0%), 0 type 4 (0%) and 3 type 5 (16.7%). All type 3 cases were articular side re-tears (type 3a). Articular side re-tear was seen in 9 cases (50%) and bur- 29 Comparison Study of Postoperative Pain Control for sal side re-tear was seen in 3 cases (16.7%). Significant differences Arthroscopic Rotator Cuff Repair: Continuous Epidural versus between articular side re-tear and bursal side re-tear were observed. Single-shot Interscalene Block Bursal side tear was well repaired, though articular side re-tear was SHIMOKAWA Kanichi, ITO Hitoshi, Department of Orthopaedic seen in 50% after a double row repair for delamination. Surgery, Omachi Municipal Hospital The purpose of this study was to assess the efficacy of an alterna- tive method of postoperative pain control with continuous epidural 27 Clinical Significance of a Low Signal Change of a Rotator and single-shot interscalene block for arthroscopic rotator cuff repair Cuff High Signal Intensity Portion on MRI after Repair (ARCR). One-hundred consecutive patients who underwent ARCR ITSUBO Toshiro, UCHIYAMA Shigeharu, KATO Hiroyuki, Depert- were enrolled. Continuous epidural (CE) group consisted of 52 ment of Orthopaedic Surgery, Shinshu University School of Medicine cases, 32 men and 20 women, whose average age at surgery HATA Yukihiko, NAKAMURA Kouichi, ISHIGAKI Norio, Division of was 64.5 years old. Single-shot interscalene block (IS) group con- Rehabilitation, Shinshu University sisted of 48 cases, 28 men and 20 women, whose average age at MURAKAMI Narumichi, Sports Medicine Center, Aizawa Hospital surgery was 63.9 years old. Surgery was done under general anes- KOBAYASHI Hirokazu, Department of Orthopaedic Surgery, thesia, performed by a single surgeon in a beach-chair position. The Chushin-Matsumoto Hospital patients’ backgrounds of both groups were not uneven. In group-CE, We reported that the high signal intensity on a portion of rotator a 2%-lidocaiine was administrated intra-operatively and 0.2%-ropi- cuff insertion seen on MRI after rotator cuff repair was not re-tear last vacaine was given via a continuous epidural catheter for 2-4 days year. At this time, we reported on whether a low signal intensity postoperatively. In group-IS, a 0.75%-ropivacaine was injected change showed recovery of the rotator cuff itself. We investigated into the interscalene compartment following induction of general an- 71 shoulders of 70 cases showing high intensity signal changes of esthesia. Postoperative rehabilitation started at 1POD, in the same the rotator cuff on MRI 6 months after rotator cuff repair. We classi- regimen for all patients. We evaluated pains at the time of recovery fied the patients into 2 groups: the 1st consisted of 37 patients (‘‘A’’ from general anesthesia, at night of the surgery, at the time of the 1st group) with low signal intensity changes of the rotator cuff, and the postoperative rehabilitation and the patients’ satisfaction of postop- 2nd group consisted of 34 patients (‘‘B’’ group) with no low signal erative pain using VAS-scales (0-10). We also investigated complica- intensity changes. For the clinical evaluation, we examined the pa- tions related to anesthesia, functional evaluation using the Japanese tients’ JOA score, UCLA score, range of motion (ROM) of the shoul- Orthopaedic Association shoulder score (JOA-SS) and QuickDASH. der, and MMT. For the configuration evaluation, we estimated the The ratio of patients who had pain at recovery from general an- muscle belly thickness of the SSP, ISP, and deltoid muscles, and the esthesia was 7.6% in group-CE and 8.3% in group-IS, without a dif- fatty degeneration of the SSP muscle using Nakagaki’s classifica- ference. Pain the night of the surgery, patients’ satisfaction also had tion. We compared and reviewed each item at 6 months and 1 no significant differences. Pain at first postoperative rehabilitation year postoperatively. Based on the clinical evaluation, the UCLA was significantly lower in group-CE. No complications including in- and JOA scores were more significantly improved at 1 year postop- fection or prolonged nerve palsy were observed in any cases. Post- erative time than at 6 months (P < .01). Based on the configuration operative functional scores using JOA-SS and QuickDASH after evaluation, recovery of the thickness of the ISP muscle belly and fatty surgery had no difference in either group. We conclude that a sin- degeneration were statistically significant in the A group (P < .01, gle-shot interscalene block was safe and effective for arthroscopic P < .01, respectively), but the B group did not show significant re- rotator cuff repair equal to a continuous epidural block. covery. Based on these results, we believed that low signal intensity changes show recovery of the rotator cuff itself. 30 Analgesic Efficacy of Subacromial Infusion of Ropivacaine after Arthroscopic Rotator Cuff Repair 28 The Evaluation of MRIs of the Rotator Cuff re-Tear after TSUDA Eiichi, ISHIBASHI Yasuyuki, FUKUDA Akira, TSUKADA ARCR; Muscle Atrophy and Fat Tissue Degeneration Harehiko, INOUE Ryo, TOH Stoshi, Department of Orthopaedic MATSUURA Koumei, Department of Orthopaedic Surgery, Kita- Surgery, Hirosaki University Graduate School of Medicine kyushu Municipal Wakamatsu Hospital The purpose of this study was to determine the analgesic efficacy ISHITANI Eiichi, Morooka Orthopaedic Hospital of subacromial infusion of ropivacaine after arthroscopic rotator cuff We evaluated the characteristics in MRIs of the re-tear cases after repair. Fifty-three patients who underwent arthroscopic rotator cuff ARCR and the changes of a postoperative rotator cuff at a later pe- repair under general anesthesia were involved in this study. All pa- riod. We examined 40 cases (average age 65.8 years old) on tients received postoperative NSAID medication (lornoxicam whom we performed ARCR from May 2003 to April 2007 and 12mg/day) for 5 days. In 34 patients, a single-dose subacromial in- who had had MRIs preoperative and at 6, 12 months postoperation. jection with 10 ml of 0.75% ropivacaine was administered at the e8 Abstracts J Shoulder Elbow Surg

end of surgery and followed by a postoperative subacromial infu- tear, and repair may not always be warranted for massive tears. The sion of 0.75% ropivacaine at 2 ml/hr for 1 to 4 days (R group). recent biomechanical studies have demonstrated that the double row As a control, 19 patients did not receive an injection or infusion of tendon-to-bone fixation was stronger and footprint coverage of the ropivacaine (C group). A visual analog scale pain score and con- double row fixation was larger than the single row or transosseous fix- sumption of postoperative additional analgesic were compared be- ation technique. Therefore, we have devised a new suture technique tween the two groups. In the R group, visual analog scale at the 1st, without suturing on the tendon named the surface-holding repair tech- 2nd and 3rd postoperative days was 4.2 6 1.7, 3.3 6 1.3 and 2.3 nique. The objectives of this study were to determine whether a new 6 1.2, respectively. This was significantly lower compared to the repair technique of rotator cuff tendons can yield a lower re-tear 5.9 6 1.2, 5.3 6 1.0 and 4.6 6 0.5 in the C group. Additional sup- rate and to obtain a better clinical outcome than previous reported positories (diclofenac 50 mg) and intramuscular injections (pentaz- methods. With regard to repair integrity of the rotator cuff at ocine 15 mg) analgesics were administered to 6 patients (18%) and a mean of 36.8 months postoperatively, according to Sugaya’s clas- 4 patients (12%) in the R group, and 14 patients (74%) and 8 pa- sification, MRI scans revealed 14 shoulders with a type-I, 4 shoulders tients (42%) in the C group, respectively. Subacromial administra- with a type-II, 4 shoulders with a type-III, 2 shoulders with a type-IV,and tion of ropivacaine is an efficient analgesic technique to reduce nothing witha type-Vrepair.Synthetically,2 shouldershad a discontin- shoulder pain after arthroscopic rotator cuff repair. uous cuff. Therefore, the re-tear rate was 8.3% (2 of 2? shoulders). In conclusion, satisfactory clinical results were obtained with the surface- holding repair technique for massive rotator cuff tears. Although OA 31 Outcomes of Early Rehabilitation Program after Rotator glenohumeral joint and upper migration of the humeral head, both Cuff Repair with Shoulder Mobilizer and Active Exercise in had progressed postoperatively in some shoulders, the incidence Flexed Position rates were no higher than those of other procedures. In re-tear rate, OIZUMI Naomi, HISADA Yukiyoshi, MINAMI Akio, Department of the rate was lower than that of other procedures. Therefore, this tech- Orthopaedic Surgery, Hokkaido University School of Medicine nique will be one of the good procedures in rotator cuff operations. SUENAGA Naoki, Department of Joint Replacement and Tissue Engineering, Hokkaido University, Graduate School of Medicine WATAYA Misako, Department of Rehabilitation, Hokushin Hospital 33 Arthroscopically Assisted Modified Debeyre’s Procedure It was sometimes difficult to perform early passive exercises after with a Fascial Patch Graft surgery for rotator cuff tear due to pain and increased muscle tonus TAKUBO Yoshinori, NAKAGAWA Haruhiko, Department of Ortho- during passive shoulder exercise. Wedeveloped a new rehabilitation paedic Surgery, Otsu Municipal Hospital protocol using an original shoulder mobilizer that can apply traction MORIHARA Toru, IWATA Yoshio, HORII Motoyuki, KUBO Toshi- and rotational motion and active exercises in supine flexed position, kazu, Department of Orthopaedics, Graduate School of Medical and reported favorable early passive ROM. The objectives of this Science, Kyoto Prefectural University of Medicine study were to compare ROM after the start of anti-gravity active exer- KUROKAWA Masao, Department of Orthopaedic Surgery, Saisei- cises and to evaluate the postoperative cuff integrity using MRIs. Sixty- kai Suita Hospital three shoulders were classified as group I (GI); no tendon-to-bone re- We have performed an arthroscopically assisted modified De- pair, or group II (GII); with tendon-to-bone repair. In the former proto- beyre’s procedure with a fascial patch graft (AMDFP). The short clin- col, passive exercises started the next day of the surgery (GI) or in one ical results and the low invasiveness were evaluated. week (GII). In the new protocol, the active exercises and the mobilizer Eight shoulders (6 males, 2 females; age, 63-76 years; average; started the next day; no passive exercises were applied. There were 67.5 years old) were examined. The shoulders of which tendon 10 former-GI, 9 new-GI, 22 former-GII, and 22 new-GII. Postopera- edges could not reach to the top of the greater tuberosity arthroscopi- tive flexion, external-rotation, and internal-rotation at 1, 2, 4, 8 weeks cally were selected for an AMDFP. The method was indicated as fol- were evaluated. In shoulders that carried out the new rehabilitation lows; the modified Debeyre’s procedure was performed with a small program and were followed-up for more than 1 year, JOA score (3-4 cm) incision. The deltoid was split (3-4 cm) along the muscle fi- was evaluated and postoperative cuff integrity was classified accord- bers at the junction of the anterior and middle 1/3. The fascial patch ing to Sugaya’s classification of MRIs at 1 year. The ROM of the new- graft was folded back, and inserted into the subacrominal space. The GIand new-GIIwas comparable or better than that of the former- medial end of the graft was sutured to the tendon edge arthroscopi- GIand former-GII. Especially, the lag between active and passive flex- cally. The distal end was sutured to the top of the greater tuberosity ion at the start of anti-gravity active exercises was smaller in the new with open technique. For evaluation of invasiveness, we examined program group. The JOA score at 1 year was 96.0 points in the new- the length of the skin incisions, the Hb and Ht data between before GIand 94.5 points in the new-GII. The cuff integrity in MRIs was clas- and after surgery, and compared the data between in the AMDFP sified as type 1 in all shoulders. The new postoperative rehabilitation and in the modified Debeyre’s procedure (D method) at our hospital. program was proved to be safe and useful in this study. The 4 shoulders (4 cases) of AMDFP were observed for more than 6 months. These clinical results were evaluated using the JOA scores. The length of skin incisions and the changes of the Hb and Ht data 32 The Clinical Outcome and Repair Integrity of Open of AMDFP were less than D method. The JOA scores of AMDFP im- Repaired Massive Rotator Cuff Tears with Surface-holding proved 81 points postoperatively from 72.6 points preoperatively. Repair Technique The AMDFP was little invasive, and the short clinical results are good.- YAMAGUCHI Hiroshi, The Department of Orthopaedic Surgery, University of Ryukyus School of Medicine SUENAGA Naoki, Department of Total Joint Replacement and 34 Clinical Results of Infraspinatus Muscle Transfer for Tissue Engineering, Hokkaido University School of Medicine Massive Rotator Cuff Tear OIZUMI Naomi, MINAMI Akio, Department of Orthopaedic Sur- ASATO Hideki, HIGA Takeya, Department of Orthopaedic Surgery, gery, Hokkaido University School of Medicine Yonabaru Central Hospital, Okinawa, Japan HOSOKAWA Yoshihiro, Department of Orthopaedic Surgery, Kai- TERUYA Hitoshi, Orthopaedic Teru Clinic, Okinawa, Japan sei Hospital KANAYA Fuminori, Department of Orthopaedic Surgery, University Although various surgical procedures have been reported on for of the Ryukyus, Okinawa, Japan rotator cuff tears, the reported re-tear rate after open, mini-open, The treatment for massive rotator cuff tear with supraspinatus mus- and arthroscopic repair has ranged from 24% to 94%, as demon- cle atrophy has not been established. We reported on satisfactory re- strated by arthrography, ultrasonografy, and magnetic resonance im- sults in patients who suffered from massive rotator cuff tear with aging. Especially in massive rotator cuff tears, the clinical outcome supraspinatus muscle atrophy by infraspinatus muscle transfer (Patte was distinctly less satisfactory than that for patients who had a smaller 1990). Five patients received infraspinatus muscle transfer. There J Shoulder Elbow Surg Abstracts e9

were 4 males and 1 female with an average age of 72 years old screws and stabilization used the coracoid transfer (modified Bris- (range, 55-81 years). All were affected in the right side (dominant tow’s procedure). Sixteen months after the operation, his shoulder side), The etiology of rotator cuff tear was fell down in 3 and unknown active range of motion became 50forward flexion, 45 abduction, in 2. All patients had rest and motion pain. Contracture of the shoul- 45external rotation and L1 level internal rotation. The Japanese Or- der was not observed and active-ROM (active range of motion) was thopaedic Association’s shoulder score (JOA score) had improved under 90 degrees except a patient. The follow-up period averaged from 58 points preoperatively to 76.5 points postoperatively. We re- 13 months (11-15 months). A brace with 30 degrees abduction ported a case of chronic unreduced fracture dislocation of the shoul- was applied in all patients after surgery. Passive ROM exercises der. It is difficult to reduce when a long time has passed since the were started the day after surgery. Active ROM exercise without dislocation. Our case was performed an open reduction and fixa- a brace was started from 6 weeks after surgery. Shoulder pain disap- tion, but his shoulder range of motion was deteriorated postopera- peared in 3 patients, and improved in 2 patients. The average active tively. But JOA score was improved. ROM improved from a preoperative 72o to postoperative 150oin flexion, 68o to 165o in abduction, and 37oto45o in external rota- tion, respectively. Supraspinatus test became negative in all patients 37 Impingement Syndrome Associated with old Type Fracture after surgery. The average JOA score improved from 46 to 92. Infra- of the Coracoid Process combined with Recurrent Anterior spinatus muscle transfer is an effective method for massive rotator cuff Dislocation of the Shoulder tear with severe supraspinatus muscle atrophy. UI Michimasa, Ui Orthopaedics Clinic OGAWA Kiyohisa, Department of Sports Clinic, Keio University TAKAHASHI Masaaki, IKEGAMI Hiroyasu, NANIWA Toyohisa, 35 Latissimus Dorsi Transfer for Irreparable Rotator Cuff Department of Orthopaedic Surgery, Keio University Tears We presented a case of a patient with impingement syndrome as- MATSUHASHI Tomoya, OIZUMI Naomi, YAMANE Shintaro, MIN- sociated with an old type fracture of the coracoid process, distal part AMI Akio, Department of Orthopaedic Surgery, Hokkaido Univer- from the insertion of the coracoclavicular ligament. A 47-year-old sity School of Medicine man had no history of direct injury, but epilepsy. He had had sublux- SUENAGA Naoki, Department of Total Joint Replacement and ation of the shoulder 4 times in the past one year. The coracoid tip Tissue Engineering, Hokkaido University School of Medicine could not be touched and he felt pain at the anterior side of the shoul- SUZUKI Katsunori, Orthopaedic Sugery, Tomakomai Oji Hospital der when a supination of the forearm was restricted. His range of mo- YAMAGUCHI Hiroshi, Department of Orthopaedic Surgery, Ryukyu tion was limited by pain, active elevation was 110(135) external University School of Medicine rotation was 30 (70) internal rotation was Th9 Th7 and horizontal Treatment for irreparable rotator cuff tears remained controversial. adduction was 110 (150). Radiographic and enhanced computed Latissimus dorsi transfer had been proposed for the treatment of irrep- tomographic examinations showed a bony Bankart lesion and an old arable tears by Gerber et al. in 1988. Our aim of this study was to in- type fracture of the coracoid process. The fragment of the coracoid vestigate outcomes of the latissimus dorsi transfer for irreparable process displaced inferolaterally. At operation, the displaced frag- rotator cuff tears. From 1992 to 2004, 7 shoulders in 7 cases which ment of the coracoid process, the conjoint tendon, coracoacromial were performed on a latissimus dorsi transfer for irreparable rotator ligament and the tendon of pectoralis minor covered an anterior cuff tears were evaluated clinically and radiographically. The aver- part of the humeral head. When the coracoacromial ligament was aged follow-up period was 78.9 months (range, 36-169). The study released from the fragment, the fragment had shifted to the medial group included seven men, with an average age of 63 years old at side. The bursa was worn away and impingement tear of the rotator the time of surgery. The outcome assessment included the JOA scores, cuff was at the anterior part of the supraspinatus and superior part of range of motion of active flexion and external rotation, internal rota- the subscapularis, under the coracoacromial ligament and the frag- tion. Osteoarthritis and upper migration of the humeral head were ment of the coracoid. Two screws were used to reattach the bony also evaluated on standardized radiographs. The averaged JOA Bankart’s lesion. But the coracoid fragment was not fixed because score improved from 41.4 preoperatively to 81.1 at the time of fol- the friction had disappeared. In this case, the shifted fragment of frac- low-up. Flexion increased from 63.3 to 140.8.Externalrotation tured coracoid process with the coracoacromial ligament and the was increased. 4 had significant progress of the osteoarthritic change conjoint tendon changed the shape of the coracoacromial arch and the upper migration of the humeral head. Femoralization of and there occurred an impingement. In a case like this, the resection greater tuberositywas appeared in4 shoulders. All 7 patientswere sat- of the coracoacromial ligament is simple and effective. isfied with their shoulder condition. The disabling pain in most patients was diminished after surgery; however, the osteoarthritic change pro- gressed in 57.1%. Further long-term follow-up should be necessary. 38 Superior Dislocation of the Shoulder with Acromional Fracture: A Case Report IRIE Toru, SHIMAZAKI Shunji, TOGIYA Satoshi, MIYOSHI Naoki, 36 Surgical Treatment for Chronic Unreduced Fracture MATSUNO Takeo, Department of Orthopaedic surgery, Asahikawa Dislocation of the Shoulder: A Case Report Medical College INOUE Jun-ichi, SAKAI Hiroya, Department of Orthopaedic NAKAGAWA Hiroshi, Department of Orthopaedic surgery, Wakka- Surgery, Saitama Medical Center, Saitama Medical University nai City Hospital AIZAWA Tomofumi, Department of Orthopaedic Surgery, Ayase MORISUE Masatsugu, Department of Orthopaedic surgery, Kitami Kosei Hospital Red-Cross Hospital SHIMADA Noriaki, Department of Orthopaedic Surgery, Kamifu- Superior shoulder dislocation was very rare in the literature. We kuoka General Hospital reported on a case of superior dislocation of the shoulder with acro- A 38-year-old man with a past history of epilepsy felt shoulder mional fracture. A 67-year-old man met with a traffic accident, and pain in the morning, but he thought that this pain was usual pain after was brought to our hospitals by ambulance in February 2007. His epilepsy. He had been treated by a bone-setter; however, his shoul- left shoulder was swollen and he could not move his left upper extrem- der pain had not cleared. He visited a hospital almost 2 years after ity. Plain radiographs revealed superior dislocation of the left shoul- his first shoulder pain; radiographs showed fracture dislocation of der joint with acromional fracture. Furthermore, fracture of the right his shoulder. He visited our hospital. His shoulder active range of mo- clavicle and fracture-dislocation of the left elbow and left hip joints tion was 150 forward flexion, 140 abduction, 5 external rotation were found. Then, we performed reduction of the left shoulder, el- and S level internal rotation. Manual muscle testing was 5 levels. Af- bow, and hip joints in the emergency room. Two weeks after the ac- ter radiographs, CT, and angiographies, he was given an open re- cident, open reduction and internal fixation were performed on the duction, the internal fixation used cannulated cancellous bone left shoulder and elbow joints. Avulsion fracture of the acromion e10 Abstracts J Shoulder Elbow Surg

was repaired with tension band wiring. Four weeks after the opera- Hospital, Nippon Medical School and Dokkyo Medical University in- tion, passive shoulder motion was permitted. After 3 months, plain dependently classified all the registered fractures according to the radiographs reveal good healing on the fracture site, but mild pain Neer classification (1970), and picked up possible valgus impacted and severe contracture of his left shoulder still remain. fractures (N ¼ 71, 11%) according to the description of Jakob (1984, 1991). Disagreement of the classification among the 3 reviewers (226/661cases) was discussed, and additional criteria for valgus im- pacted fractures (Neer 2002, Robinson 2003) were referred to. Reas- 39 Chronic unreduced Posterior Fracture-dislocation of the sessment, again performed independently by the same reviewers, shoulder: A Case Report revealed 19 (3%) valgus impacted fractures. Of these, 3 were treated OBATA Masanori, AKIUCHI Toshiro, Department of Orthopaedic conservatively, 10 by osteosynthesis, and 6 by hemiarthroplasty. The Surgery, Nishioka Dai-ichi Hospital active shoulder elevation at the follow-up was generally good in pa- A 27-year-old man sustained right shoulder injury in a bicycle ac- tients who underwent osteosynthesis, whereas poor in those who cident. The diagnosis at the first hospital visit was fracture of the prox- had been treated conservatively. The authors conclude that (i) valgus imal humerus, and he was immobilized with the arm at his side for 4 impacted fractures consist of 3-11% of proximal humeral fractures, (ii) weeks. After the physical therapy, he returned to his previous work at the 2002 Neer classification which categorized this type of fracture is a book store. Limitation of overhead activity and dullness of the shoul- a better option for clinical use, and (iii) valgus impacted fractures der during motion had continued, and he visited our clinic. Physical should be treated by osteosynthesis with care not to insult the blood examination revealed limitation of active range of motion of his right supply to the humeral head through the medial periosteum. shoulder, with flexion to 80, abduction to 70, external rotation to 0, and internal rotation to the level of the buttock with no neurologi- cal deficit. Radiographs and CTs revealed posterior dislocation of the glenohumeral joint with bone defect of the humeral head. The JOA 42 Factors Inducing Poor Outcomes of Neer’s Minimal score was 45 points. Five months after the injury, surgery was per- Displacement (1-part) Fractures of the Proximal Humerus formed. With a deltopectoral approach the humeral head was re- HASHIGUCHI Hiroshi, Department of Orthopaedic Surgery, Nip- duced, followed by transfer of the lesser tuberosity onto the bone pon Medical School Chiba Hokusoh Hospital defect (modified McLaughlin’s procedure). The shoulder was immobi- ITO Hiromoto, IIZAWA Norishige, Department of Orthopaedic Sur- lized in the handshake position for 5 weeks. The passive range of mo- gery, Nippon Medical School tion exercises were started at 3 weeks after surgery. He returned to his The purpose of this study was to analyze factors inducing poor previous work at 6 months after the surgery. One year after the sur- outcomes of Neer’s minimal displacement (1-part) fractures of the gery, active range of motion had improved with flexion to 140,ab- proximal humerus. The subjects were 183 patients with 1-part frac- duction to 100, external rotation to 50, and internal rotation to the ture, including initial and follow-up x-rays and results of shoulder mo- level of the L4, and the JOA score improved to 83.5 points. tion at the final follow-up, in the JSS database of proximal humeral fractures. There were 134 females and 49 males whose average age was 60.6 years old. Surgical neck (SN) fracture was observed 40 A Review of Fracture Types not included in Neer in 88 patients, greater tuberosity (GT) fracture in 57 patients, and Classification - 668 Cases in Database – SN-GT fracture in 38 patients. Three groups classified according ISHIGE Noriyuki, KURODA Shigehito, MARUTA Kimiko, MIKASA to results of shoulder elevation were as follows: excellent (E) group (150or more) in 97 patients, good (G) group (90 to 150)in62 Motohiko, Matsudo Orthopaedic Hospital Neer classification is popular; however, there are some cases that and fair (F) group (90 or less) in 24. Factors induced poor outcomes can not be classified by it. We reviewed a detail of fracture types by were analyzed and compared between the 3 groups. The average using Codman classification, and clarified the fracture types that age of the E-group was significantly lower than that of the G-group could not be classified and groped about for a better classification or the F-group. With regard to fracture type, 91.2% of GT fractures, method. We classified 668 cases of Database by Neer and Codman 97.4% of SN-GT fractures and 79.5% of SN fractures belonged to classifications. In case of Neer classification, we defined a fracture as the E-group or the G-group. Varus displacement at the final follow- follows: a greater tubercle displaced beyond the top of the humeral up increased in 66.7% of the patients with SN fractures of the head, a lesser tubercle clearly displaced from the humeral head or F-group. Ten patients who had suffered from complications or other shaft, surgical neck displaced over 1/3 width of the shaft. On the diseases such as dementia or rotator cuff tears obtained poor out- other hand, the valgus impacted type of Jacob classification was comes. This study suggested that treatment and rehabilitation should added to this classification. There were 19 cases of valgus impacted be applied to patients with 1-part proximal humeral fractures in con- type. And there were 23 cases that could not be classified by Neer sideration of the patients’ backgrounds and fracture types. classification in 668 cases. That number was smaller than our previ- ous report. Those 23 cases looked like types 3, 6, 14, 15, and 16 of Codman classification and humeral head fracture. Types 6 and 14 were less displaced and treated conservatively. Types 3, 15, and 43 The Evaluation of Bone Mineral Density and Bone strength 16 had anatomical neck fractures and were mainly treated opera- in the Proximal Humeral Head of Elderly People tively. These 3 types seemed to need some review of the methods of YAMADA Mitsuko, YAMAJI Tetsuo, Department of Orthopaedic treatment. We conclude that it is useful to change definitions of frac- Surgery, Fujita Health University, Second Hospital tures and add a valgus impaction type, head fracture, 3, 15, and 16 Since bone mineral density (BMD) and bone strength of the prox- types of Codman classification to the original Neer classification. imal humeral head affect the stability of the internal fixation material at the operation, we evaluated the relationship between BMD and bone strength in the proximal humeral head using cadaver humerus. The BMD of 10 cadavers humerus (mean age, 79.2) was ana- 41 Valgus Impacted Fractures of the Proximal Humerus – An lyzed by XP26 (Norland Co.). BMD was measured at 4 regions of Analysis of JSS Database – interest (top is top of the humeral head, medial is the area of sub- TAMAI Kazuya, Dokkyo Medical University chondral bone at the glenoid side, middle is the middle of the hu- OHNO Wataru, Koga Red-Cross Hospital meral head and GT is the greater tuberosity). On the coronal Wereviewed 661proximalhumeral fractures registered to the JSS plane the osteotomy was performed on the middle of the humeral database to clarify the incidence, nature and treatment of valgus im- head and sliced 1 cm thickness to compare the anterior slice with pacted fractures. Three shoulder experts from Matsudo Orthopaedic the posterior slice at the same region. The maximum load value J Shoulder Elbow Surg Abstracts e11

was measured by the compression test using a universal material ex- fair in 1. The average score of pain improved from 15.1 points to amination machine (Instron 4505). 26.8 points. Postoperatively, impingement tests (Neer, Hawkins, Mean BMD (g/cm2)the top was 0.50, themedial 0.64,the middle Ellman) were negative in all cases. Arthroscopic decompression 0.44 and the GT 0.51. The medial region was significant difference and G-T plasty for impingement syndrome after fracture of the from the middle (P < .05). The mean maximum load value (N) was humeral greater tuberosity can provide good pain relief and 347 at the top, 437 at the medial 136 at the middle and 209 at the improve the functional results. GT. The medial was significant difference from the top and the middle (P <.05). By comparison between the anterior slice and the posterior slice at the same region, there was significant difference at the top, the medial, the middle and GT (P <.01). There was positive correlation be- 46 Clinical Characteristics of Asymptomatic Rotator Cuff Tear tween BMD and the bone strength at each region (P <.05). YAMAMOTO Atsushi, TAKAGISHI Kenji, OSAWA Toshihisa, KO- Our result shows that the BMD indicates the bone strength in the BAYASHI Tsutomu, NAKAJIMA Daisuke, SHITARA Hitoshi, Department proximal humeral head. To get more stability of the screws, the edge of Orthopaedic Surgery, Gunma University Graduate School of of screw must be inserted into the top or medial region at the poste- Medicine rior side. The purpose of this study was to investigate clinical characteris- tics of asymptomatic rotator cuff tears. Two-hundred and eleven of 283 shoulders diagnosed with rotator cuff tears by ultrasonography (male, 81 of 114 shoulders; female, 130 of 169 shoulders; mean 44 Isolated Fractures of the Greater Tuberosity of the age, 65.5 years old) were divided into 2 groups according to the Proximal Humerus - Relationship between Fracture type and presence or absence of pain: asymptomatic rotator cuff tear group Displacement (group A) and symptomatic rotator cuff tear group (group S). Age, NAKAGAWA Yoshiyuki, OKUMOTO Hiroki, Department of Ortho- sex, occupation, dominant arm, trauma history, impingement sign, paedic Surgery, Uda City Hospital degree of active anterior elevation, abduction strength and external The purpose of this study was to show the new classification of rotation strength were compared between these 2 groups. Using lo- the isolated fractures of the greater tuberosity of the proximal hu- gistic analysis, the clinical characteristics of asymptomatic rotator merus, and to report the relationship between fracture type and dis- cuff tears were also investigated. There were 185 shoulders placement. This study consisted of 94 cases (56 females and 38 (65.4%) in group A, and 98 shoulders (34.6%) in group S. Although males, 55 cases without dislocation and 39 cases with dislocation) there was no significant difference in age, sex or occupation, dom- with isolated fractures of the greater tuberosity. The mean age was inant arm injury (A;51.9%, S;72.4%), positive impingement sign 60.2 years old (range, 18-96 years). The greater tuberosity con- (A;5.9%, S;41.8%), active anterior elevation (A;150.7, S;146.1), sisted of the 3 facets; superior facet, middle facet and inferior facet. weakness of abduction strength (A;16.8%, S;40.8%), and weak- Fractured facets and the amount of displacement of the greater tu- ness of external rotation strength (A;12.4% S;36.7%) significantly berosity were investigated. In cases without dislocation, the superior differed. Logistic analysis showed that dominant arm (odds ratio ¼ facet was fractured in 8 cases, the middle facet in 14, the superior 2.99), impingement sign (odds ratio ¼ 10.18) and external rotation and middle facets in 9, the middle and inferior facets in 14, the su- strength (odds ratio ¼ 3.10) were significant. When all 3 factors perior and the middle and the inferior facets in 10. In cases with dis- were negative, 93.8% of the rotator cuff tears in this series were location, the superior and middle facets were fractured in 16 cases, asymptomatic. Asymptomatic rotator cuff tear involved more fre- the middle and inferior facets in 2, the superior and the middle and quently the nondominant arm, was negative for impingement sign, the inferior facets in 21. Advance of the displacement of the greater and showed greater active anterior elevations preserved abduction tuberosity was seen in 2 cases without dislocation and in 8 cases strength and external rotation strength. with dislocation, whose mean age was 75.7 years old. Various frac- ture types were showed in cases without dislocation, and cases with dislocation had large fractured fragment including the middle facet. 47 Clinical Findings Affected by the Shoulder Pain of the The cases with dislocation often had advance of the displacement of Patient with Rotator Cuff Tears the greater tuberosity, and should be treated carefully, especially in ISHIGAKI Norio, HATA Yukihiko, NAKAMURA Koichi, Division of the aged. Rehabilitation Medicine, Shinshu University School of Medicine MURAKAMI Narumichi, Sports Medical Center, Aizawa Hospital KOBAYASHI Hirokazu, Department of Orthopaedic Surgery, Chushin-Matsumoto Hospital 45 Clinical Outcome of Arthroscopic Decompression and G-T ITSUBO Toshiro, UCHIYAMA Shigeharu, and KATO Hiroyuki, Plasty for Impingement Syndrome after Fracture of the humeral Department of Orthopaedic Surgery, Shinshu University School of greater tuberosity Medicine KIKUGAWA Kazuhiko, OKUHIRA Nobuyoshi, Department of When we chose a therapy for rotator cuff tear, there was no def- Orthopaedic Surgery, Mazda Hospital inite basis, but presence and degree of a pain tended to become We assessed the clinical outcome of arthroscopic decompres- a large element of the judgment. The aim of this study was to inves- sion and G-T plasty for impingement syndrome after fracture of the tigate it about the factor influencing the difference of pain, and to humeral greater tuberosity. Five cases of impingement syndrome af- prove that characteristic of pain with rotator cuff tear. A consecutive ter fracture of the humeral greater tuberosity were treated since series of 328 shoulders in 328 patients with rotator cuff tear under- 2003. The cases were 3 male and 2 female, with an average age went operative treatment were concerned since July 1997 to Decem- of 47 years old. The mean follow-up period was 14 months. The du- ber 2006. These patients were divided with 3 groups: group A ration from trauma to surgery ranged from 8 to 25 months. Three consisted of 135 shoulders which had a night pain (Japanese Ortho- shoulders were fracture of the humeral greater tuberosity alone paedic Association score (JOA score) of pain < 10); group B con- and 2 shoulders were 3 part fractures. Preoperatively, impingement sisted of 60 shoulders which pain was produced in daily living tests (Neer, Hawkins, Ellman) were positive in all cases. All cases activities (JOA score of pain ¼ 15); group C consisted of 133 shoul- were treated by arthroscopic subacromial decompression and ders which produced pain only in working or no pain (JOA score of 2 shoulders were associated with removal of exostoses of the great pain > 20). All patients had erevations of their age, sexuality, the tuberosity. The clinical evaluation was performed using the JOA affected side, a contraction period, history of trauma, tear size score, impingement sign and range of motion. The average post- and range of motion. Age, sexuality, the affected side, contraction operative JOA score increased significantly from 62 points to 87 period, history of trauma, tear size did not recognize a significant points. The clinical results were excellent in 2 cases, good in 2, difference between 3 groups. In the range of motion, groups e12 Abstracts J Shoulder Elbow Surg

A and B were limited in comparison with group C in flexion and C7 mobilize precisely under direct vision, and useful for simultaneous thumb distance (CTD) significantly, and group A was limited in com- repair of torn supra- and infraspinatus tendons. parison with groups B and C in extension significantly.

50 Morphologic Improvement of Repaired Cuff after 48 How Does the Tear Part of a Rotator Cuff have an Arthroscopic Rotator Cuff Repair - Single-Row versus Double- Influence on Rotator Muscle Power? Row Fixation - MATSUURA Koumei, Department of Orthopaedic Surgery, Kita- KOMATSUDATatsuro, KOIKE Yoichi, SATO Katsumi, Department of kyushu Municipal Wakamatsu Hospital Orthopaedic Surgery, Tohoku Rosai Hospital ISHITANI Eiichi, Morooka Orthopaedic Hospital Although several clinical and anatomical results after arthro- We divided the rotator cuff tear part according to the articular sur- scopic rotator cuff repair were reported, the longitudinal improve- face of the greater tubercle of the humerus and conducted an investi- ment of cuff integrity was not studied. The purpose of this study gation into the influence that each gave to each rotator muscle power. was to compare the morphologic improvement of repaired cuff From October 2004 to April 2007, we evaluated 80 patients and the functional outcome of single-row (SR) and double-row (DR) with rotator cuff tear. We defined the location of cuff tear the facet fixation after arthroscopic rotator cuff repair. A consecutive series as zone 1; superior facet as zone 2; anterior part of middle facet of 131 shoulders with rotator cuff tears were evaluated using the Jap- as zone 3; posterior part of the middle facet, and as over zones anese Orthopaedic Association (JOA) shoulder index. There were 1, 2, 3. We measured both sides of the muscle strength of abduction, 66 shoulders (55 males, 11 females, mean 59 years-old) in the SR external rotation, internal rotation, internal rotation using Microfet. group and 65 shoulders (47 males and 18 females, mean 61 The muscle strength of the unaffected side became significantly years-old) in the DR group. Average follow-ups were 30 and 22 < < big in order of abductor power external rotation power adduc- months, respectively. To evaluate the postoperative cuff integrity, < tor power (P .001). Each muscle strength test showed that MRIs were performed at 3, 6, and 12 months postoperatively. The JOBE<40, ISP surgeries for full-thickness rotator cuff tears and tenodesis was performed in 4 cases. We evaluated the clinical mea- postoperative good clinical results at a minimum 6 months follow- sures using the JOA-shoulder score (JOA-SS), QuickDASH, range-of- up. The average age at the time of rotator cuff repair surgery was motion, and muscle strength. Also we assessed repair integrity using 55.5 years old (range, 38-65 years). Each sample was fixed in for- MRI T2-weighted imaging 6 and 12 months postoperatively. The av- malin and embedded in paraffin. Staining was performed with he- erage size of full-thickness defect of SSC was 25.6 mm in coronal di- matoxylin eosin and toluidine blue. Fibrocartilage formation was mension and 19.4 mm in sagittal. No complications including nerve observed at the repaired site of the bone-tendon junction in 4 of 6 injury were observed in all cases. JOA-SS improved from 51.5 to 92, samples (67%). However, they were unlike normal enthesis com- QuickDASH also changed from 76.1 to 13.6. Internal rotation was posed of 4 distinct zones. Fibrous connective tissue interposition enhanced from L4 to L1, flexion improved from 100to 163. Muscle without any fibrocartilage formation was recognized in the other strength using MicroFET, internal rotation improved from 59.8 N to 2 samples (33%). Fibrocartilage formation was observed at the re- 98 N. No apparent re-tear was observed 6 and 12 months postop- paired site of bone-tendon junction after arthroscopic rotator cuff re- eratively. We conclude that arthroscopic SSC repair is a safe and ef- pair. This indicates that the natural healing potential has remained at fective procedure, because the surgeon will be able to diagnose and the bone-tendon junction of torn rotator cuff tendon. J Shoulder Elbow Surg Abstracts e13

52 The clinical results of arthroscopic rotator cuff repair gery; bDepartment of Joint Replacement and Tissue Engineering, without anchors Hokkaido University School of Medicine; cDepartment of Orthopae- ISHIGE Noriyuki, KURODA Shigehito, MARUTA Kimiko, MIKASA dic Surgery, Ryukyu University School of Medicine Motohiko, Matsudo Orthopaedic Hospital Patients with pain and dysfunction from glenohumeral arthritis ac- Arthroscopic rotator cuff repair without anchor has been done companied with irreparable rotator cuff tears have had few treatment since April 2005. We reported the clinical results of this operative options. Recently, reverse shoulder prosthesis was reported in the method. We reviewed the 28 shoulders (18 men, 10 women) that management of this problem; however, the high complication rate were operated on from April 1, 2005, to July 31, 2007. The aver- was one of the problems with this procedure. This study investigated age age was 62.4 years at operation. The operation was performed the clinical results after hemiarthroplasty with a tendon muscle trans- as follows: several sutures went through the footprint and the rotator fer in patients with glenohumeral arthritis accompanied with severe cuff by perforated Kirschner wire from the distal of the greater tuber- rotator cuff deficiency. We investigated 13 consecutive patients cle, and the torn rotator cuff was put on the footprint by mattress su- (mean age, 65 years) who were followed up for more than 1 year tures and bridging sutures. We used Kuroda’s knot as a suture postoperatively. Seven patients had rheumatoid arthritis. Pectoralis method and tied them at the distal of the greater tubercle. The aver- major transfer was performed in 6 cases, latissimus dorsi transfer age postoperative periods were 12.8 months. We reviewed the pre- was performed in 6 cases, and combined transfer of both tendons operative periods, the torn widths, the Japanese Orthopaedic was performed in 1 case in addition to hemiarthroplasty of the hu- Association (JOA) scores, and the postoperative magnetic reso- merus. The postoperative mean Japanese Orthopaedic Association nance images (MRIs). The average preoperative period was 6.2 scores were 63.3, 74.7, and 87.5 in the pectoralis major transfer, lat- months, and the average torn width was 1.4 cm. The average of issimus dorsi transfer, and combined tendon transfer groups, respec- the total score of JOA was improved significantly from 72.8 preop- tively. The mean flexions of the shoulder were 62.5, 116.7, and eratively to 94.0 postoperatively. There were 2 shoulders with 150, respectively. No infection, nerve injury, or dislocation was broad high intensity on the attachment of the rotator cuff in postop- documented. A hemiarthroplasty with a latissimus dorsi transfer could erative MRIs. Only 1 shoulder had a lower functional score than provide satisfactory results in patients with glenohumeral arthritis with at preoperation. Without anchors, we got a good result and this an irreparable rotator cuff tear. Although a hemiarthroplasty with method seemed to be useful. However, some patients had poor a pectoralis major transfer could provide good pain relief, flexions range of motion of external rotation. The direction of repair of torn of the shoulder were limited and unsatisfactory. Weaknesses of mus- rotator cuff and the physical therapy are among variables that cle strength associated with rheumatoid arthritis and anterosuperior need to be reviewed. instability during flexion are considered as reasons for poor results.

53 Clinical effect of surgical repair of massive rotator cuff 55 Operative treatment versus conservative treatment for tears great tuberosity fracture of the humerus displaced superior HATA Yukihikoa, ISHIGAKI Norioa, NAKAMURA Koichia, MURA- between 5 mm and 1 cm KAMI Narumichib, KOBAYASHI Hirokazuc, ITSUBO Toshirod, OSAWA Toshihisaa, TAKAGISHI Kenjia, KOBAYASHI Tsutomua, UCHIYAMA Shigeharud, KATO Hiroyukid, aDivision of Rehabilita- SUZUKI Hidekia, TAMAMOTO Atsushia, SHITARA Hitoshia, SHI- tion Medicine; dDepartment of Orthopaedic Surgery, Shinshu Uni- NOZAKI Tetsuyaa, ARITA Satorub, aDepartment of Orthopaedic versity School of Medicine; bSports Medicine Center, Aizawa Surgery, Gunma University Graduate School of Medicine; bDepart- Hospital; cDepartment of Orthopaedic Surgery, Chushin-Matsu- ment of Orthopaedic Surgery, Gunma Cardiovascular Center moto; Hospital Operative treatment has been recommended for great tuberosity The purpose of this study was to examine the clinical effects of fracture of the humerus with more than 5 mm of upper displacement. surgical repair of massive rotator cuff tears. We examined 70 shoul- The purpose of this study was to compare the operative treatment ders of 69 patients who underwent surgery for massive rotator cuff with conservative treatment of great tuberosity fracture of the hu- tears. Evaluations using the University of California, Los Angeles merus displaced between 5 mm and 1 cm. We retrospectively eval- (UCLA) score were performed preoperatively, and at 6 months uated 10 shoulders in 10 patients with great tuberosity fracture of and 2 years postoperatively. Evaluations using magnetic resonance the humerus. In all patients, there were 5- to 10-mm displaced frag- imaging (MRI) were performed at 6 months and 2 years postopera- ments of great tuberosity fracture of the humerus. The operative tively. For all patients, there was significant improvement for all items group consisted of 5 shoulders (3 men and 2 women). Their mean of the UCLA score between the preoperative evaluation and the age was 55 years (range, 47-71 years). The average duration of fol- 6-month postoperative evaluation. There was also a significant low-up was 16.2 months (range, 12-24 months). The conservative improvement in the UCLA score, with the exception of active group had 5 shoulders (5 women). The mean age was 67.4 years forward flexion, between 6 months and 2 years postoperatively. (range, 61-73 years). The average duration of follow-up was 24.8 For MRIs, there was a significant improvement in the thickness of months (range, 6-47 months). We evaluated the range of motion the anterior deltoid muscle between 6 months and 2 years postoper- (flexion, abduction, and external rotation) and the Japanese Ortho- atively; on the other hand, there was no significant improvement in paedic Association (JOA) score. In the operative group, flexion was thickness or fatty degeneration of the supraspinatus muscle between 143 625.6, abduction was 144.4 6 25.2, external rotation 6 months and 2 years postoperatively. These results suggested that was 34.4 6 15.7 and the JOA score was 84.3 points. In the con- surgical repair of massive rotator cuff tears could not improve the servative group, flexion was 138 6 34.2, abduction was 131 6 thickness and fatty degeneration of repaired cuff muscles. However, 24.1, external rotation was 35 6 15.4, and the JOA score was it could improve shoulder function and the thickness of the anterior 83.6 points. There were no significant differences between the op- deltoid muscle. Consequently, surgical repair of massive rotator erative group and the conservative group. This study documented cuff tears has definite clinical effects. the same clinical results for operative treatment and conservative treatment of the great tuberosity fracture of the humerus with more than 5 mm of upper displacement. 54 A shoulder hemiarthroplasty with a tendon muscle transfer for glenohumeral arthritis associated with severe rotator cuff deficiency 56 Surgical treatment of the proximal humeral fractures YAMANE Shintaroa, OIZUMI Naomia, MINAMI Akioa, SUENAGA IZAKI Teruaki, SHIBATAYozo, NAITO Masatoshi, Department of Or- Naokib, YAMAGUCHI Hiroshi, aDepartment of Orthopaedic Sur- thopaedic Surgery, Fukuoka University, School of Medicine e14 Abstracts J Shoulder Elbow Surg

We studied 76 patients (43 men and 33 women) who required tion to T11, on average. The mean Japanese Orthopaedic Associa- surgical intervention for proximal humeral fractures at Fukuoka Uni- tion score was 95.2 points. The Targon PH nail had straight shape versity between 1994 and 2005. The medical records and plain ra- and 4 interlocking screws; and each was placed at a different level diographs were reviewed. The mean age was 54.2 years old. The of the humeral head. Thus, the rigid stabilization allowed early phys- mean follow-up was 54 months (range, 15-92 months). Each frac- iotherapy, even in osteoporotic patients. We believe that it is impor- ture was classified according to the Neer classification. The Japa- tant to reduce the displacement exactly, to decide the suitable entry nese Orthopaedic Association shoulder score was used to assess point, and also to repair the rotator cuff. functional outcome. Our fundamental strategy for displaced proxi- mal humeral fractures was plate osteosynthesis. Other osteosynthe- sis procedures included 4 retrograde Kirschner wire fixations and 3 interlocking intramedullary nails for 2-part surgical neck fracture, and 6 tension band wiring or screwing, or both, for 2-part greater 59 Operative treatment for proximal humeral fractures with tuberosity fracture. In 3- and 4-part fracture/fracture dislocations T2 proximal humeral nailing system for patients older than 60 years, we chose a humeral head replace- SHIMADA Noriakia, INOUE Jun-ichib, SAKAI Hiroyab, AIZAWA To- ment. Union occurred in all cases except 1, which required a hu- mofumic, aDepartment of Orthopaedic Surgery, Kamifukuoka Gen- meral head replacement. Most patients were satisfied with the eral Hospital; bDepartment of Orthopaedic Surgery, Saitama postoperative functional results. Seventeen complications during Medical Center, Saitama Medical University; cDepartment of Ortho- the follow-up included contractures in 10, axillary nerve palsy in paedic Surgery, Ayase Kousei Hospital 2, complex regional pain syndrome in 2, Kirschner wire backout The purpose of this study was to evaluate the surgical outcome in 1, varus deformity of the humeral head in 1, and nonunion in 1. for the osteosynthesis of proximal humeral fractures repaired with T2 proximal humeral nails. We examined 18 shoulders in 18 pa- tients (7 men and 11 women) with proximal humeral fracture treated using the T2 proximal humeral nailing system from January 2005 to December 2006, with a minimum postoperative follow-up 57 Intramedullary fixation with tension band wiring for of 3 months. Patients were an average age of 69.7 years (range, proximal humeral fractures 32-91 years). All patients were injured in a fall. The fracture type MATSUMURA Noborua, TAKAHASHI Masaakib, MIKASA Takahi- was a 2-part fracture in 15 patients and a 3-part fracture in 3. koc, aDepartment of Orthopaedic Surgery, Eiju General Hospi- General anesthesia was initiated, and the fracture was reduced us- tal; bDepartment of Orthopaedic Surgery, National Hospital ing fluoroscopy. The nail was inserted from the proximal end of the Organization Tokyo Medical Center; cDepartment of Orthopae- humerus, and interlocking screws were inserted on both ends of dic Surgery, Saiseikai Yokohamashi Tobu Hospita the nail. The average operation time was 50.4 minutes (range, The purpose of this study was to evaluate the clinical results of our 35-113 minutes). Range of motion exercise was started the day af- surgical treatment for proximal humeral fractures. Between April ter the operation. Bony union, range of motion in flexion of the 2003 and March 2007, we performed intramedullary fixation shoulder joint, and postoperative complications were examined. with tension band wiring as the surgical treatment of proximal hu- The average follow-up was 8.1 months (range, 3-19 months). meral fractures for elderly patients. We followed up 31 patients (3 No repeat displacement of the fracture was seen after surgery. men and 28 women) for more than 6 months after surgery in a pop- A bony union was obtained in an average of 17.1 weeks (range, ulation aged older than 70 years. The patients were average age of 12-25 weeks). The mean postoperative range of motion was 78.8 years (range, 70-90 years). Twenty-one patients were classi- 107.8 in flexion (range, 60-170). There were 2 patients with fied as 2-part fracture, 5 as 3-part fracture, 4 as 4-part fracture, backout of the proximal interlocking screw. Good stability was ob- and the last patient was unclassifiable by the Neer classification. tained with the T2 proximal humeral nailing system. The range of Clinical results were evaluated retrospectively at 6 months after sur- motion exercise was started immediately after surgery; however, gery. We observed bone union in all the patients. The mean postop- the range of motion at the follow-up was not satisfactory. The post- erative Japanese Orthopaedic Association score was 80.5 (range, operative exercise program should be reconsidered. It is neces- 60-96). No patients had an evidence of avascular necrosis of the hu- sary to improve the system to prevent backout of the proximal meral head. However, we observed loosening of the fixation in 2 pa- interlocking screw. tients and protrusion of the intramedullary Kirschner wires, followed by subacromial impingement, in 6 patients. Satisfactory outcomes were achieved with our surgical procedure, and we regarded this method as useful for proximal humeral fractures for the elderly. How- ever, some contrivances are needed to avoid complications after sur- 60 Clinical results of intramedullary nailing for surgical neck gery in particular cases. fracture of the humerus SAKAI Kiyoshi, Department of Orthopaedic Surgery, Toyama Red Cross Hospital We report the clinical efficacy and technical importance of intra- medullary nailing for surgical neck fractures of the humerus. From 58 An antegrade straight interlocking nail for proximal January 2001 to December 2006, we surgically treated 56 proxi- humeral fractures mal humeral fractures. Of these, 29 (28 surgical neck fractures SHINMURA Koutaroa, TAKASE Katsumib, YAMAMOTO Kengob, and one 3-part fracture of the proximal humerus) were repaired aDepartment of Orthopaedic Surgery, Tokyo Metropolitan Ohtsuka with intramedullary nailing using Polarus humeral nails. We retro- Hospital; bDepartment of Orthopaedic Surgery, Tokyo Medical Uni- spectively investigated the fracture type, coexistence of rotator cuff versity tear, postoperative radiograph, pain, and range of motion using For proximal humeral fractures with osteoporosis, we performed the Japanese Orthopaedic Association shoulder score. Postopera- internal fixation with an antegrade straight interlocking nail (Targon tive varus inverted displacement happened in 4 of the 28 fractures PH) and had good results via rigid stabilization. The purpose of the (surgical neck fracture), and these cases preoperatively showed present study was to evaluate the therapeutic results and to examine varus inverted displacement with the short neck (the fracture line the peculiarity and the surgical technique of this implant. Twenty-four was less than 2 cm below the top of the greater tuberosity). This cor- patients were treated with this implant. Six months after the surgery, rection of lost cases showed a delayed union and less abduction they had flexion of 153, external rotation of 63, and internal rota- range of motion. Cutout of the nail from the humeral head was found J Shoulder Elbow Surg Abstracts e15

in 1 fracture, which was saved by an endoprosthesis. Except for 63 Humeral head retroversion in asymptomatic shoulder: those 5 patients, the fractures healed with good clinical results. Co- Relation to gender, dominant hand, and history of sports existence of rotator cuff tear showed no significant clinical differ- activities ence compared with patients in this series with a normal cuff. KOBAYASHI Shuzoa, OGAWA Kiyohisab, IKEGAMI Hiroyasuc, IN- Intramedullary nailing for surgical neck fracture can generally pro- OKUCHI Watarud, WATANABE Anrie, aDepartment of Orthopaedic vide good clinical results. In case of varus inverted displacement Surgery, Kitasato Institute Medical Center Hospital; bSports Clinic with the short neck, however, we should consider various technical and cDepartment of Orthopaedic Surgery, Keio University, School interventions for the prophylaxis of reinversion and overcorrection of Medicine; dDepartment of Orthopaedic Surgery, Tokyo Metropol- (valgus inversion) fixation assisted by tension band wiring (transten- itan Health and Medical Treatment Corporation Ohkubo Hospital; dinous valgus retraction). Patients with osteoporosis need careful eDepartment of Orthopaedic Surgery, Ito Municipal Hospital postoperative management to avoid a catastrophic state such as The purpose of this study was to evaluate humeral head retrover- cutout of the humeral head. sion in asymptomatic shoulders. We compared the differences be- tween the dominant side and the nondominant side, and sex differences. Computed tomography was done on 470 shoulders in 235 healthy volunteers. Of these, 113 were men (mean age, 30.4 years) and 122 were women (mean age, 30.0 years). Nine men and 3 women were left-handed, and 104 men and 119 women 61 The effect of humerus varus deformity in proximal humeral were right-handed. We classified the cohort into 4 groups according fractures to the history of sports activities for 2 years or longer in the growth HATAKEYAMAYuji, KOBAYASHI Moto, Department of Orthopaedic period until the patients were 18 years old. We adopted our original Surgery, Nakadori General Hospital measuring method using Nobuhara’s anatomic axis to draw the hu- The purpose of this study was to investigate the effect of humerus meral head axis. For men, the mean value of the humeral head ret- varus deformity in proximal humeral fractures. The study included roversion was 37.7 6 10.4 on the dominant side and 31.6 6 15 patients (2 men and 13 women) who underwent open reduction 9.3 on the nondominant side. For women, the humeral head retro- and plate fixation between February 2004 and November 2006. version was 31.2 6 9.2 on the dominant side and 25.9 6 10.2 All patients had surgical neck, 2-part proximal humeral fractures on the nondominant side. There were significant differences be- and were divided into 2 groups. Group A had 8 patients with hu- tween the dominant side and nondominant side for men and women merus varus deformity of less than 25. Group B had 7 patients as evaluated with the unpaired t test (P <.0001). The measurements with humerus varus deformity of more than 25. The mean age of humeral head retroversion on the dominant side were larger than was 71.8 and 76.4 years old respectively, and the average fol- on the nondominant side regardless of sex in all groups classified ac- low-up was 19.5 and 20.4 months, respectively. There were no sig- cording to sports participation during a growth period. In addition, nificant differences in the ages and follow-up periods between the 2 the measurements in men tended to be larger than in women regard- groups. In group A, the mean active flexion was 119, abduction less of the dominant hand side with the sports classification. How- was 110, external rotation was 46, internal rotation was to ever, when the sex and the dominant hand side were the same, T10, and the average Japanese Orthopaedic Association (JOA) the measurements of humeral head retroversion between the 4 score was 87.7 points. In group B, the mean active flexion was groups were not significantly different. If there were some acquired 121, abduction was 108, external rotation was 40, internal rota- elements, except unilateral sports strain affecting the development of tion was to T10, and the average JOA score was 88.6 points. Bone humeral torsion, it is possible that the differences of the measure- union occurred in all patients except 1, who had pseudarthrosis. ments between the dominant side and nondominant side, or male There was no humeral head avascular necrosis. The average hu- and female gender, meant the differences of the degree of the expo- meral head inclination angle was 130 in group A and 109˚ in sure. group B, with respective mean humerus varus deformity of 10.9 and 36.4 (P ¼.0006). The average interval between the acromion and the greater tuberosity was 12.5 mm in group A and 9.5 mm in group B. There were no significant differences in the range of motion 64 Three-dimensional kinematic analysis using computed and JOA score between the 2 groups. Humerus varus deformity of tomography of the shoulder joint during arm elevation more than 25 did not result in any significant differences in the HONDA Hiroaki, MORIHARA Toru, TAKATORI Ryota, IWATA outcome of the operative treatment. Yoshio, TOKUNAGA Daisaku, INOUE Nozomu, KUBO Toshikazu, Department of Orthopaedic Surgery Science, Kyoto Prefectural Uni- versity of Medicine No accurate data have been reported on three-dimensional (3D) kinematics of the shoulder that include the sternoclavicular joint. The purpose of this study was to analyze the 3D kinematics of sternocla- 62 Clinical results of hemiarthroplasty for proximal humeral vicular, acromioclavicular, and glenohumeral joints during arm ele- fractures using cable wire system vation using computed tomography (CT). We examined 6 shoulders KONISHIIKE Taizo, Okayama Red Cross Hospital of 3 healthy male volunteers (mean age, 28.7 years old). CT images We had used needle wires to fix greater and lesser tuberosity of the shoulder (including sternum, clavicle, scapula, and humerus) fragments and humeral prostheses. This report evaluated the cable were obtained in the neutral position and head-touch position. A 3D wire system for shoulder hemiarthroplasty. From 1999 to 2006, model of each bone was created from the CT images. The movement we performed hemiarthroplasty on 13 patients (3 men and 10 of each bone was calculated by volume merge and a custom com- women) who were an average age of 63 years. Two groups were puter program. The movements of the bone were seen by the Euler compared: Group A (6 patients) underwent hemiarthroplasty with angle, which used 3 rotational parameters and 3 quantities of move- simple needle wire from 1999 to 2003. Group B (7 patients) under- ment. We measured the rotation and quantity of movement of each went hemiarthroplasty with a cable wire system (the compounded bone from the neutral to head-touching positions. We calculated the needle wire with compression device) from 2004 to 2006. We eval- sternoclavicular joint movement as the difference of movement of the uated the results by the Japan Orthopaedic Association (JOA) score. clavicle from the sternum, acromioclavicular joint movement as the The average postoperative JOA score was 69.2 points in group A difference of the scapula from the clavicle, and glenohumeral joint and 86.2 in group B. The cable wire system was considered to be movement as the difference of the humerus from the scapula. Our effective to fix the greater and the lesser tuberosities. measurement method was different from past methods; however, e16 Abstracts J Shoulder Elbow Surg

our results were similar. This method is correct and can measure peared in 14 shoulders within approximately 2 weeks. The remain- a wide area in one step. Clinical application will be possible in ing 2 shoulders showed improvement of range and scores on the the future. visual analog scale. We performed arthroscopic release of SSN in 16 shoulders with the sensory disturbance at posterior aspect of the shoulder. All shoulders were improved after the surgery. The sen- sory disturbance at posterior aspect of the shoulder is useful in the 65 Do healthy subjects elevate both shoulder joints in the diagnosis of SSN palsy, especially in a patient with a massive rota- same manner? tor cuff tear. YANO Yuichiroa, TAMAI Kazuyaa, NOHARA Yutakaa, YOSIZAKI Kuniob, HAMADA Junichiroc, aDepartment of Orthopaedic Surgery, Dokkyo University School of Medicine; bKoriyama Institute of Health Science; cDepartment of Orthopaedic Surgery, Kuwano Kyoritsu 67 The correlation between the occurrence and seasons in Hospital calcified tendinitis of the shoulder NAGOSHI Mitsurua, HASHIZUME Hiroyukib, KONISHIIKE Taizoc, The study was conducted to clarify whether healthy individuals d e a elevate and lower their dominant and nondominant shoulder joints HIROOKA Takahiko , UCHIDA Keiji , Nagoshi Orthopaedic Clinic; bKasaoka Daiichi Hospital; cOkayama Red Cross Hospital; in the same manner and if this was significantly valuable to under- d e stand the pathology of shoulder diseases, including rotator cuff Onomichi Municipal Hospital; Jinno Hospital tear; impingement syndrome, stiff shoulder, and loose shoulder. Calcified tendinitis is a common shoulder disease accompanied Twenty young, healthy participants (17 men and 3 women; average with severe pain. We experienced many cases of calcified tendinitis age, 22.6 years) participated in this study. They randomly elevated during some short periods in a year. We examined the correlation and lowered both shoulder joints in the scapular plane 3 times and between the occurrence of calcified tendinitis and the seasons. were recorded by a 3-dimensional motion analyzer. We calculated The study investigated 212 patients (72 men and 140 women) the scapulohumeral rhythm in each 10 and analyzed the setting with acute calcified tendinitis who visited 12 hospitals during 2 phase. There was statistically no significant difference in the scapu- years (January 2005 to December 2006) in the Chugoku and Shi- lohumeral rhythm between the dominant and nondominant shoul- koku area. The average age was 57.1 years. The day of the first ders. Scapulohumeral rhythm was stable (3.5) from 60 in medical examination and the numbers of cases were examined. elevation to 50 in lowering; however, individual variation of scap- The correlation between the occurrence and 4 seasons (March- ulohumeral rhythm (more than 3.5) was identified, except in the pre- May, June-August, September-November, December-February) viously shown angles. To elevate both shoulder joints in the same and the correlation in the occurrences between each area were sta- manner means that we can compare the scapula motion in both tistically analyzed. The correlation between the occurrence and sea- shoulders and arm elevation in patients with shoulder disorders. sons was not seen (Wilcoxon signed rank test). In winter, the mean The setting phase is defined as up to 60 in elevation; moreover, value of the number of cases of calcified tendonitis tended to be less. a similar phase as the setting phase with various scapular motion There was a strong correlation in occurrence between the Sanyo is recognized in the lowering motion. West and Shikoku Setouchi areas (Spearman correlation coefficient, 0.53997; P ¼.0065). More cases and analysis in various points of view are needed for evidence of the correlation between the occur- rence and season.

66 Sensory disturbance of posterior aspect of the shoulder: One of the indicators of suprascapular nerve palsy with rotator 68 Clinical results of arthroscopic surgery for calcium deposit cuff tear in rotator cuff, calcific tendinitis of the rotator cuff a b b SUENAGA Naoki , OIZUMI Naomi , MIMAMI Akio , YAMAGU- GOTO Hideyuki, HORIUCHI Osamu, HISAZAKI Shinji, TSUCHIYA c a CHI Hiroshi , Department of Joint Replacement and Tissue Engi- Atsushi, OTSUKA Takanobu, Department of Orthopaedic Surgery, b neering and Department of Orthopaedic Surgery, Hokkaido Nagoya City University School of Medicine c University School of Medicine; Department of Orthopaedic Sur- The purpose of this study was to report the clinical outcomes of gery, Ryukyu University School of Medicine arthroscopic resection and repair for calcium deposits in the rotator Several causes have been reported for suprascapular nerve cuff. In this study, 10 patients (11 shoulders) were treated by arthros- (SSN) palsy. To diagnose SSN palsy, usually these findings were copy. The patients were a mean age of 51.6 years (range, 34-68 useful, as follows: atrophy of the supraspinatus and infraspinatus years). The procedure was combined with arthroscopic resection muscle, muscle weakness of abduction and external rotation, no of calcium deposits and rotator cuff repair using simple side-to-side or small rotator cuff tear, and abnormal findings on electromyogra- sutures or suture anchors. Arthroscopic capsular release was added phy (EMG). However, it was difficult to diagnose SSN palsy in pa- for the shoulders with joint contracture. At a mean follow-up of 23 tients with massive rotator cuff tear. The objectives of this study months (range, 7-49 months), the clinical results were evaluated were to investigate the effectiveness of a sensory disturbance on by means of the Japanese Orthopaedic Association (JOA) scores. the posterior shoulder in diagnosing SSN palsy in patients with rota- JOA scores were improved from 66 points preoperatively to 92 tor cuff tear. Sixteen shoulders in 16 patients (10 men and 6 women) points postoperatively. One shoulder required open exploration were involved in this study. The average age was 65 years old. Pa- to detect the calcium deposit. Postoperative radiographs showed tients had sensory disturbance of the posterior aspect of the shoulder no recurrence of calcium deposition in the rotator cuff. In conclusion, and received arthroscopic release of the suprascapular ligament. the present study shows that arthroscopic resection and rotator cuff The size of rotator cuff tear showed incomplete tear in 3 shoulders, repair for calcium deposit of rotator cuff had favorable clinical small tear in 3, medium tear in 2, large tear in 1, and massive tear in results. 7. Preoperative sensory disturbance, the results of EMG analysis, oc- cupation ratio of supraspinatus/infraspinatus muscle in magnetic resonance imaging, and outcomes of sensory disturbance were evaluated. Sensory disturbance in the posterior aspect of the shoul- 69 A clinicopathologic study of rotator cuff tears associated der was observed in all patients. In EMG examinations, there was with CPPD crystal deposition no difference compared with the normal side except in 2 shoulders. HASHIMOTO Takashia, INUI Hiroakia, NOBUHARA Katsuyaa, The average occupation ratio was 46.7% in supraspinatus muscle HAMADA Tetsuob, aNobuhara Hospital and Institute of Biomechan- and 68.5% in infraspinatus muscle. Sensory disturbance disap- ics; bDepartment of Surgical Pathology, Kyushu Rosai Hospital J Shoulder Elbow Surg Abstracts e17

Calcium pyrophosphate dihydrate (CPPD) crystal deposition into at the 5 o’clock position. A second anchor with tied suture (B) was fibrocartilage and hyaline cartilage is a well-recognized condition placed medially to the glenoid rim at the 4 o’clock position. Both that sometimes causes acute arthritic attack. We found 5 patients of the ends of the B suture were passed through the inferior gleno- (4 women and 1 man) who had evidence of CPPD crystal deposition humeral ligament–labral complex with mattress stitches. After mak- in the tendon proper during histopathologic examination of 118 ing a post of suture A and one end of suture B together as post consecutive shoulders with rotator cuff tears. suture, a sliding knot was tied (suture-reel technique). A third anchor The patients were an average age of 71.2 years (range, 65-82 (C) was inserted on the glenoid at the 3 o’clock position. Suture C years old). The average duration of symptoms before surgical inter- and another end of suture B were tied in the same manner. The shoul- vention was 11.6 months (range, 5-36 months). There was 1 partial- ders were immobilized in internal rotation for 3 weeks. We evalu- thickness tear and 4 full-thickness tears (1 small, 1 medium, and 2 ated the complications and postoperative Japan Shoulder Society large tears). None of the patients had had an obvious traumatic shoulder instability score (JSS-SIS). There was no neurovascular in- event. These patients were studied clinicopathologically. Abnormal jury or recurrence of dislocation. The mean postoperative JSS-SIS deposits were demonstrated radiographically at the distal insertion was 97.8. This method is considered to be a secure fixation, and of the rotator cuff as linear or punctuate lesions in all cases. In surgi- a further follow-up is needed. cal observation, white chalk-like deposits were macroscopically seen at the stump of torn tendons. In pathologic examination, char- acteristic rhomboid-shaped crystals with positive birefringence un- der polarized light were identified as CPPD in torn tendon tissues and easily distinguished from dystrophic calcification histologically. 72 ABER-MRI evaluation after arthroscopic Bankart repair Neither distinct inflammatory nor granulomatous changes were surgeries observed at the tendon tissues around CPPD crystal deposition. NAKAMURA Nobuyuki, ITO Yoichi, TOMO Hiroyasu, NAKAO CPPD crystal deposition into torn tendons was considered to be a de- Yoshihiro, MANAKA Tomoya, NAKA Yoshifumi, MATSUMOTO Is- generative process because of the absence of inflammatory and shin, SAKAGUCHI Kimikazu, TAKAOKA Kunio, Department of Or- granulomatous changes. Deposition of CPPD in torn tendons may thopaedic Surgery, Osaka City University Graduate School of be associated to the vulnerability of tendon fibers. Medicine Reports have been published on the utility of the use of various suture anchors with arthroscopic Bankart repair. The use of MRI with abduction and external rotation (ABER-MRI) to evaluate the Bankart lesions has been reported. The aim of this study was to eval- 70 Shoulder hemiarthroplasty for rheumatoid arthritis with uate arthroscopic Bankart repaired condition after ABER-MRI with the coracoid transplantation to the glenoid metal or absorbable anchors and to examine the utility for this IKEGAMI Hiroyasu, OGAWA Kiyohisa, NAKAMICHI Noriaki, more than 6 months later. We evaluated with ABER-MRI 21 shoul- SHIONO Shohei, KOBAYASHI Shuuzo, Department of Orthopae- ders (14 men and 7 women) treated by an arthroscopic Bankart re- dic Surgery, School of Medicine, Keio University pair with a knotless or absorbable anchor. The average age at We reported on hemiarthroplasty for rheumatoid arthritis with operation was 26.2 years (range, 17-46 years). The follow-up after coracoid transplantation to the glenoid. From 2002 to 2005, 11 pa- an arthroscopic Bankart repair was 6 months. The used anchors tients (8 women and 3 men; age range, 51-76 years old), 12 shoul- were 10 metal and 11 absorbable. The evaluation items were ders (6 right, 6 left) were treated. The mean follow-up was 3.5 years compared according to (1) the possibility of image evaluation of (range, 2 years-5 years and 4 months). Our surgical technique was each anchor with with ABER-MRI, (2) evaluation with ABER-MRI coracoid transplantation to the glenoid with screws and hemiarthro- and normal position MRI, and (3) group classified by ABER-MRI ex- plasty. We preserved the coracoid-acromion ligament by abrading amined correlated with the clinical results. We evaluated 18 of 21 subperiosteally from the coracoid. We used the Japanese Orthopae- shoulders with ABER-MRI, consisting of 7 of 10 metal anchors dic Association (JOA) score system to assess the results. Pain relief (70%) and 11 of 11 absorbable anchors (100%). In 7 of 18 shoul- was obtained in most of the patients. The JOA score improved ders that we were able to evaluate with ABER-MRI, the normal posi- from the average of 39 points preoperatively to 81 points postoper- tion MRI was impossible to evaluate. In repaired condition evaluated atively. In patients with rheumatoid arthritis, good exposure of the by ABER-MRI in 18 shoulders, 14 shoulders (77.8%) were type I, 3 operative field could not be obtained easily because of the medial- shoulders (16.7%) were II, and 1 shoulder was type III. The good ization of the humeral head. Our method of coracoid osteotomy is shoulder results were all type I, and the re-subluxation and the under- effective not only for good exposure of the operative field but also achivement shoulders were type II and III. In postoperative evalua- for the bone stock of the glenoid destruction. tion, MRI is more useful for an absorbable anchor than a metal anchor. In the good results condition with ABER-MRI, the clinical results are good.

71 A new fixation method of arthroscopic Bankart repair: bridging suture fixation by suture-reel technique HIRATA Masazumia, KUROKAWA Masaoa, MORIHARA Torub, 73 Recovery of muscle strength in arthroscopic Bankart IWATA Yoshiob, HONDA Hiroakib, KUBO Toshikazub, HORII Mo- repaired shoulders with postoperative external rotational toyukic, aDepartment of Orthopaedic Surgery, Saiseikai Suita Hos- position pital; bDepartment of Orthopaedics, Graduate School of Medical SATO Hidekia, KANOH Shinkichia, NAGAO Akihikob, aDepart- Science, Kyoto Prefectural University of Medicine; cDepartment of ment of Orthopaedic Surgery, Aomori Rosai Hospital; bDepartment Orthopaedic Surgery, Kyoto Interdisciplinary Institute Hospital of of Orthopaedic Surgery, Kurosu Hospital Community Medicine The purpose of this study was to clarify the recovery term of the We introduced a new arthroscopic Bankart repair technique that shoulder muscle strength in patients who underwent arthroscopic provided a double-layer footprint fixation by using a bridging suture Bankart repair with postoperative external rotational position. Ten with a sliding knot. We investigated this technique in 4 men with patients underwent arthroscopic Bankart repair for recurrent ante- traumatic anterior shoulder instability. The mean age at operation rior shoulder instability and were placed in a postoperative rota- was 22.5 years, and the mean follow-up was 7 months. After the gle- tional position for 3 weeks. Before surgery, at 6 weeks, 3 months, noid rim was resurfaced, the anchor (A) was inserted on the glenoid and 6 months after surgery, the shoulder muscle strength at 90 of e18 Abstracts J Shoulder Elbow Surg

flexion, 90 of abduction, internal rotation, and external rotation at sification. We thought that the damage of trapezoid or conoid liga- 90 of flexion was measured with a Kin ComTM. Side-to-side differ- ment participated in the severity of joint subluxation on type 2. On ences were evaluated for each measurement, and the strength of the patients with type 2 or 3, we performed enhanced magnetic res- the operated shoulder was compared with the preoperative onance images (MRIs) to study the damage of both ligaments. There strength. The strength in all directions of the operated shoulder were 8 patients (6 men, 2 women), and their mean age was 37 years was significantly reduced at 6 weeks after surgery. The strength of (range, 24-58 years). According to Tossy’s criteria, these patients flexion, abduction, and internal rotation was recovered to the preop- consisted of 1 patient in type 1, 3 in type 2, and 4 in type 3. We per- erative level by 3 months after surgery, and the strength of external formed enhanced MRIs in all patients within 3 days after injury and rotation did not change throughout the study period. A percentage evaluated coracoclavicular ligaments, consisting of the trapezoid comparison of the strength of the operated shoulder with the healthy and conoid ligaments. Both trapezoid and conoid ligaments rup- side was 91% in flexion, 85% in abduction, 87% in internal rotation, tured in all cases of type 3. On the other hand, the conoid ligament and 83% in external rotation at 6 months after surgery. In this study, did not show clear abnormal findings, but the trapezoid ligament the recovery of the muscle strength of the Bankart repaired shoulders ruptured in all cases of type 2. We recognized the rupture of the trap- required more than 6 months. However, the clinical results showed ezoid ligament in all cases of type 2. From the results, we concluded that no patients had recurrence after surgery, indicating that the mus- that detailed evaluation of acromioclavicular joint separation could cle strength at 6 months after surgery could be adopted as the index not be made by one of these used classifications. of postoperative rehabilitation.

76 Treatment of acute grade III acromioclavicular separation 74 The anatomy of the coracoclavicular ligaments NAKASE Junsuke, KITAOKA Katsuhiko, MUNEHIRO Teppei, TO- TAKASE Katsumia, YAMAMOTO Kengoa, ITO Masahirob, MIYAKI MITA Katsuro, Department of Orthopaedic Surgery, School of Med- Masayoshib, aDepartment of Orthopedic Surgery and bDepartment icine, Kanazawa University of Anatomy, Tokyo Medical University Although treatment of acute grade III acromioclavicular separa- Acromioclavicular joint separation is an usual injury in everyday tion remains controversial, there has been a recent trend toward ini- practice. The selection of the surgical procedure for these patients has tial conservative treatment in most cases. We have performed been made according to the severity of the separation or the damage conservative treatment of acute grade III acromioclavicular separa- to the coracoclavicular ligaments. However, evaluation on the radio- tions since 2001. If symptoms remain after conservative treatment, graphic findings was not estimated on the trapezoid ligament and co- we perform surgery by a modified Dewar method. The present study noid ligament individually, but by the damage to all of the was performed to review our therapeutic strategy. Eight patients coracoclavicular ligaments. Furthermore, type 2 in Tossy’s or Rock- were treated conservatively with a sling for comfort through progres- wood’s criteria did not definitely indicate the severity of damage in sive early range of motion as tolerated. We investigated the clinical the coracoclavicular ligament. Not many studies have been done results with Japan Shoulder Society acromioclavicular (JSS-AC) joint of the anatomy and the function of the trapezoid ligament. We re- score. The results of conservative treatment were favorable in 6 of 8 viewed the detailed anatomy of the trapezoid ligament and the co- patients, and the average JSS-AC joint score was 95.2 points. Two noid ligament in 40 specimens from 20 deceased donors (8 men patients underwent surgery by the modified Dewar method because and 12 women) who were a mean age of 71.3 years (range, 62- of pain and easy fatigue, and their JSS-AC joint scores improved from 82 years). As an anatomic study in the coracoclavicular ligament, 74 and 80 points to 98 and 100 points, respectively. The use of we reviewed the running direction and attachment site of both the a sling without reduction of the acromioclavicular joint, followed trapezoid and conoid ligaments. The trapezoid ligament began at by a graduated exercise program, led to acceptable clinical results. the front two-thirds in the base of the coracoid process and directed Treatment of patients with persistent pain of the acromioclavicular toward the inferior surface of the clavicle. The attachment site ex- joint using the modified Dewar method resulted in improvement. tended a mean 18.7 mm (range 13-26 mm) in length and a mean These observations confirmed the efficacy of our therapeutic strategy 14.3 mm (range, 13-15 mm) in width. The conoid ligament began for the treatment of acute grade III acromioclavicular separation. at the rear one-third in the base of the coracoid process and directed toward to the conoid tubercle in the clavicle. The attachment site ex- tended a mean 21 mm (range, 15-30 mm) in length and 47 mm (range, 3-6 mm) in width to 45.4 (range, 35-55 mm) on the posterior margin of the clavicle. This study indicated the strength of the differen- 77 Clinical results of modified Phemister procedure (four-in- tiation in the severity of damage that existed between the trapezoid one procedure) for acromioclavicular dislocation and conoid ligament on the acromioclavicular joint separation. MIKASATakahikoa, HAMADA Kazutoshib, ASHIZAWAYukob,MAT- SUMURA Noboruc, IKEGAMI Hiroyasud, TAKAHASHI Masaakie, YAMANAKA Kaoruf, aDepartment of Orthopaedic Surgery, Saisei- kai Yokohamashi Tobu Hospital; bDepartment of Orthopaedic Sur- gery, Shizuoka Red Cross Hospital; cDepartment of Orthopaedic 75 The evaluation of the coracoclavicular ligaments for the Surgery, Eiju General Hospital; dDepartment of Orthopaedic Sur- acromioclavicular joint separation by the enhanced magnetic gery, School of Medicine, Keio University; eDepartment of Ortho- resonance images paedic Surgery, National Hospital Organization Tokyo Medical TAKASE Katsumia, YAMAMOTO Kengoa, ITO Masahirob, MIYAKI Center; fYamanaka Orthopaedic Clinic Masayoshib, aDepartment of Orthopedic Surgery and bDepartment Our modified Phemister procedure (4-in-1 procedure) consists of of Anatomy, Tokyo Medical University coracoclavicular ligament repair, Kirschner (K)-wire fixation of the Acromioclavicular joint separations were divided into 3 types by acromioclavicular joint, acromioclavicular ligament repair, and Tossy. Generally, type 2 presented subluxation of acromioclavicular overlapped suture of the deltoid and trapezium muscles in 1 inci- joint and did not indicate the damage of coracoclavicular liga- sion. The K wires are removed between 8 and 10 weeks after the ments. On the other hand, type 3 presented dislocation of that joint surgery. The purpose of this study was to investigate the results of and suggested rupture of the coracoclavicular ligaments. However, our 4-in-1 procedure for acromioclavicular dislocation. From the trapezoid and conoid ligaments, which were composed of the 2000 to 2006, 37 shoulders with Rockwood classification types coracoclavicular ligaments, were not estimated in detail in that clas- III to V acromioclavicular dislocation underwent operations at J Shoulder Elbow Surg Abstracts e19

Saiseikai Kanagawaken Hospital and Shizuoka Red Cross Hospital. of 17 patients who had undergone arthroscopic distal clavicle resec- The average age at operation was 39.6 years (range, 17-63 years). tion with a minimum 3 months of follow-up. The average age at the The clinical results were evaluated by the Japan Shoulder Society time of surgery was 58.1 years. Clinical evaluation consisted of 7 (JSS) score for acromioclavicular dislocation. Anteroposterior radio- different items: duration of the symptom, cause of the disease, ac- graphic views were used to evaluate rates of acromioclavicular dis- companied shoulder lesion, volume of the bone resection, tender- location, coracoclavicular distances, acromioclavicular ness of the AC joint, horizontal adduction test, and postoperative osteoarthritis, and ossification of the coracoclavicular ligament. complications. The average duration of the preoperative symptom These factors were examined statistically by using nonparametric was 31.0 months. Causes of the disease were overuse in 13 pa- tests. The postoperative JSS scores (ranges) for type III/type IV/ tients, after types I and II AC joint injury in 2, and other major trau- type V were 97.8 (93-100)/86.0 (82-90)/95.9 (82-100; P > matic events in 2. Impingement syndrome was present in all patients. 0.05). Acromioclavicular dislocation rates (ranges) for type III/ Fourteen cases of superior labrum anteroposterior lesion, 11 cases type IV/type V after the removal of K wires were 6.89% of rotator cuff tears, and 1 case of long head of the biceps tear (0%-22.2%)/28.6% (0%-57.1%)/32.5% (0%-83.3%; P > .05). were observed. The average volume of distal clavicle resection Coracoclavicular distances (range) for type III/type IV/type V after was 12.8 mm (range, 7-20 mm). AC joint tenderness completely dis- the removal of K wires were 85.7% (30.0%-125%)/133% (85.7%- appeared in 11 patients, and mild AC joint tenderness remained in 180%)/141% (57.1%-257%; P > .05). Ossification of coracocla- 6. No pain was recorded in the horizontal adduction test. All the pa- vicular ligament (type III/type IV/type V) was observed in 16.7%/ tients were satisfied with the results, without major complications. 50.0%/44.8% (P > .05). Acromioclavicular osteoarthritis Our results showed arthroscopic distal clavicle resection is an effec- (type III/type IV/type V) was observed in 33.3%/50.0%/34.5% tive surgical procedure for the treatment of painful AC joint osteoar- (P > .05). The clinical results of the 4-in-1 procedure were satisfac- thritis. tory, but there is the necessity to reconsider the term, the location, and the technique of K-wire fixation.

80 A comparison of clinical results between Bosworth screw and clavicle hook plate for comminuted clavicle distal end fracture 78 A new surgical procedure of the coracoclavicular HIROOKATakahikoa, HASHIZUME Hiroyukib, NAGOSHI Mitsuruc, ligaments for the acromioclavicular joint separation aDepartment of Orthopaedic Surgery, Onomichi Municipal Hospi- b TAKASE Katsumi, SATO Yuka, MIZOUE Tatsuro, YAMAMOTO tal; Department of Orthopaedic Surgery, Kasaoka Daiichi Hospi- c Kengo, Department of Orthopedic Surgery, Tokyo Medical Univer- tal; Nagoshi Orthopaedic Clinic sity We compared patients who had undergone surgery with a clav- Many surgical procedures have been described for the patients icle hook plate for comminuted clavicle distal end fracture with those with type V acromioclavicular joint separation classified by Rock- with an additional Bosworth screw. Twenty-four patients were exam- wood’s criteria. The results of the surgical procedures were satisfac- ined. Bosworth’s method was performed on 14 shoulders, and plat- tory. However, these procedures did not reconstruct a correct ing was performed on 11 shoulders. The final outcome was coracoclavicular ligament. In this study we tried to reconstruct the co- assessed with the elevation of the shoulder, Japanese Orthopaedic noid ligament and trapezoid ligament, which was composed of the Association (JOA) scores, and the rate of bone union. The mean el- coracoclavicular ligaments, using the palmaris longus tendon and evation of the shoulder was 167.9 in the Bosworth group, which an artificial ligament with an end button. We reviewed the postoper- was significantly higher than the 155.0 in the plating group. The ative results of the 7 patients (6 men, 1 woman) on whom we per- mean JOA pain score was 28.9 points in the Bosworth group and formed the reconstruction of a correct coracoclavicular ligament 28.6 points in the plating group, showing no significant difference after more than postoperative 6 months. Patients were a mean between the 2 groups. The complications were 2 cases of Bosworth age of 39 years (range, 22-58 years) at the time of treatment. The screw loosening, 1 case of a broken screw, and 1 case of nonunion mean waiting period to the surgical procedure was 14.5 days in the Bosworth group, and 2 cases of clavicle shaft fracture at the (range, 10-24 days), and in 2 patients only the conoid ligament immediate proximal site of plate in the plating group. The advan- was reconstructed. Pain, including night pain and motion pain, tages of Bosworth’s method were relatively less invasive surgery, was not noted in every patient. The disturbance of range of motion low operation expense, and early recovery of function after removal in the shoulder joint had recovered in only 1 month postoperatively. of the Bosworth screw, and those of the plating methods were rigid The radiographic evaluations showed that in 2 patients, who had fixation and comparatively good acquisition of bone union. had only reconstruction of the conoid ligament, the acromioclavicu- lar joint remained subluxated, but the reduced position in that joint remained in 5 patients at their final consultation. Nevertheless, de- spite the demerits of excision of the palmaris longus, the results of our procedure were highly satisfactory. 81 A medical check of shoulder joints of high-school pitchers by the Hara test: Second report OSAWA Toshihisa, TAKAGISHI Kenji, KOBAYASHI Tsutomu, SU- ZUKI Hideki, YAMAMOTO Atsushi, SHITARA Hitoshi, SHINOZAKI Tetsuya, Department of Orthopaedic Surgery, Gunma University 79 Advantages of arthroscopic distal clavicle resection for the Graduate School of Medicine treatment of acromioclavicular joint osteoarthritis The purpose of this study was to elucidate the relationship be- TOMO Hiroyasua, ITO Yoichib, NAKAO Yoshihirob, MANAKA To- tween shoulder girdle disorders of baseball players and the Hara moyab, NAKAYoshifumib, NAKAMURA Nobuyukib, MATSUMOTO test. We investigated 133 pitchers of the Gunma High School Base- Isshinb, SAKAGUTI Kimikazub, TAKAOKA Kuniob, aDepartment of ball Association. The checklists comprised shoulder pain at the time Orthopaedic Surgery, Yamamoto-Daisan Hospital; bDepartment of of pitching and the Hara test (11 items). The correlation between Orthopaedic Surgery, Osaka City University Graduate School of shoulder pain at the time of pitching and each checklist was exam- Medicine ined. Thirty-one pitchers had shoulder pain at the time of pitching. The purpose of this study was to evaluate the clinical results of ar- The significant relations were as follows: SSP test, impingement throscopic distal clavicle resection for the treatment of painful acro- test, horizontal flexion test, elbow push test, and hyperexternal rota- mioclavicular (AC) joint osteoarthritis. We evaluated 17 shoulders tion test (HERT). We thought that the useful checklists were the SSP e20 Abstracts J Shoulder Elbow Surg

test, impingement test, horizontal flexion test, elbow push test, and The improvements of endurance strength and limiting the number of HERT. According to the logistic regression analysis, SSP test and im- pitches are considered to be necessary to prevent throwing shoulder pingement test, and HERT were important items for shoulder girdle injuries. disorders of baseball players.

84 A change of shoulder range of motion after 80 fastball 82 Dynamic evaluation of supraspinatus and infraspinatus pitches in elementary school pitchers muscle contraction by ultrasonography OSUGA Tomoaki, IWAHORI Yusuke, KATO Makoto, SATO Keiji, KOBAYASHI Tsutomu, TAKAGISHI Kenji, OSAWAToshihisa, YAMA- Department of Orthopaedic Surgery, Aichi Medical University MOTO Atsushi, SHITARA Hitoshi, Department of Orthopaedic Sur- School of Medicine gery, Gunma University Graduate School of Medicine The aim of this study was to investigate the changes of shoulder The purpose of this study was to examine the contraction of ranges of motion after 80 fastball pitches in elementary school supraspinatus and infraspinatus muscles during abduction or exter- pitchers. We studied 10 elementary school baseball pitchers. Shoul- nal rotation of the glenohumeral joint by ultrasonography. A total der internal rotation (IR) and external rotation (ER) with the arm ab- of 136 baseball pitchers in high schools belonging to the Gunma ducted 90 (2nd IR and ER), IR with the arm flexed 90(3rd IR), Prefectural High School Baseball Federation were examined. Of glenohumeral abduction (Abd), and horizontal flexion (HF) were these, 76 were pitchers in whom no abnormal change of the rotator measured bilaterally at 3 points of time: before pitching, immedi- cuff was detected by ultrasonography. The pitchers were males, with ately after 80 fastball pitches, and the day after pitching. At the 3 a mean age of 16.6 (range, 15-17) years. The contraction of supra- points, there were no significant differences between the dominant spinatus and infraspinatus muscle during abduction in the scapular and nondominant shoulders in 2nd IR, 2nd ER, 3rd IR, HF, and plane and external rotation in neutral position of the glenohumeral Abd, except in HF on the next day of pitching. These good condition- joint were evaluated. When we evaluated the infraspinatus muscles, ings could be produced by continuous feedback of medical the transverse fibers parallel to the scapular spine (ISPT) and muscu- checkup. Between the 3 points of time, there were no significant dif- lar fibers parallel to the lateral border of the scapula (ISPO) were ex- ferences in 2nd IR, 2nd ER, 3rd IR, HF, and Abd. These results could amined. During abduction and external rotation, there were no be caused by the small number of subjects, youthfulness, good con- significant differences in the contraction of supraspinatus and infra- ditioning of the players, and the practice pitch. spinatus muscles between the pitching and nonpitching sides. In the contraction of the infraspinatus muscles during abduction, the ISPT decreased in both shoulders, while the ISPO increased. There was a significant difference between the ISPT and ISPO during abduc- tion. There were no significant differences in the contraction of 85 A change of shoulder range of motion after abdominal supraspinatus and infraspinatus muscles between the pitching and muscle load test in baseball players with throwing shoulder or nonpitching sides. In the contraction of infraspinatus muscles during elbow abduction, the ISPT decreased in both shoulders, while the ISPO in- IWAHORI Yusuke, KATO Makoto, OSUGA Tomoaki, SATO Keiji, creased. Department of Orthopaedic Surgery, Aichi Medical University School of Medicine The purpose of study was to investigate a change of shoulder range of motion after the abdominal muscle load (AML) test in base- ball players with throwing shoulder or elbow. We studied 36 base- 83 The strength characteristics of dynamic stabilizer of ball players with throwing elbow or shoulder. The average age was shoulder in throwing athletes 14.2 years (range, 9-29 years). Shoulder internal rotation (IR) and YOSHIMATSU Toshinori, YOSHIMATSU Shunichi, MOCHIZUKI Ka- external rotation (ER) with the arm abducted 90 (2nd IR and ER), zunaria, YOSHIMATSU Chiakib, EDA Homareb, SAITO Akiyoshic, IR with the arm flexed 90 (3rd IR), horizontal flexion (HF), and ab- RYU Junnosukec, aDepartment of Orthopaedic Surgery, Chikuma duction (Abd) were measured bilaterally on the first visit, after the Central Hospital; bDepartment of Orthopaedic Surgery, Tokyo Jikei- AML test, and on the final visit. The 2nd IR, 3rd IR, HF, and Abd of kai Medical School; cDepartment of Orthopaedic Surgery, Nihon the dominant shoulder significantly decreased, and the 2nd ER of University School of Medicine the dominant shoulder significantly increased compared with the The aim of this study was to identify the features of isokinetic nondominant shoulder on the first visit. The 2nd IR, 3rd IR, HF, and shoulder and hip muscle strength of throwing athletes. Twenty com- Abd of the dominant shoulder significantly increased after the petitive high school baseball players were studied. None had a his- AML test compared with the first visit. There were no significant dif- tory of shoulder pain. The tests were conducted using a Biodex ferences between results on first visit and after the AML test in the 2nd System 3 multijoint dynamometer. The shoulders were tested for their ER of the dominant shoulder and the 2nd IR, 2nd ER, 3rd IR, HF, and internal (IR) and external (ER) rotator muscle strength on the scapula Abd of the nondominant shoulder. The shoulder range of motion on plane, and hips were tested for their IR and ER muscle strength. We the final visit was close to that after the AML test. A negative correla- examined the data of concentric isokinetic strength at low and high tion was observed between the shoulder range of motion improve- angular velocities. In addition, we examined the data of concentric ment after the AML test and the age. We noticed the AML test isokinetic endurance strength at a high angular velocity. Shoulder showed that the muscular factors accounted for posterior tightness and hip muscle strengths at the high angular velocity were signifi- of the dominant shoulder in baseball players. cantly low compared with the low angular velocity. Shoulder ER strengths were significantly low compared with IR strengths at high angular velocity, and ER/IR ratios were significantly low at high an- gular velocity. In addition, shoulder ER endurance strength was sig- nificantly low compared with IR, and shoulder ER/IR ratios 86 Pain provocation test to detect posterior capsular tightness decreased with muscle fatigue. Imbalance of IR and ER strengths in throwing shoulder injury of the shoulder was one of the important factors of throwing shoulder NAKAGAWA Shigetoa, MIZUNO Naokoa, YONEDA Minorub,YA- injuries. From this study, it was difficult for shoulders to keep the bal- MADA Shinichib, GOUROKU Takahirob, TAKE Yasuhirob,HAYA- ance of IR and ER strengths at high angular velocity and with fatigue. SHIDA Kenjic, aDepartment of Orthopaedic Sports Medicine, J Shoulder Elbow Surg Abstracts e21

Yukioka Hospital; bDepartment of Sports Medicine, Osaka Kosei- postoperative dislocation or subluxation because a bony structure nenkin Hospital; cDepartment of Orthopaedic Surgery, Osaka Po- is constructed at the anterior glenoid. We assessed 2 men who un- lice Hospital derwent revision surgery after the Bristow procedure. One patient The purpose of this study was to investigate the efficacy of 2 new was 28 years old at revision surgery, and the primary surgery pain provocation tests to detect posterior capsular tightness seen in was Bristow-Bankart procedure. He fell while skiing 6 months after throwing shoulder injury. Fifty-eight shoulders with throwing shoul- the primary surgery and sustained a subluxation. At 11 months after der injury were investigated. First, the forced flexion internal rotation the primary surgery, he underwent revision surgery. The coracoid (FIR) test and the maximum abduction external rotation (ABER) test process was again fixed by a screw, and a Bankart repair was were performed preoperatively as pain provocation tests. The FIR added. At 56 months of follow-up, Japanese Shoulder Society shoul- test was defined as positive when the patient noted pain at the pos- der instability score (JSS-SIS) was 90 and subluxation had improved. terior or deep aspect of the shoulder on forced internal rotation at The other patient was 34 years old at revision surgery, and primary 90 flexion of the shoulder, and the ABER test was defined as posi- surgery was Bristow procedure only. Redislocation occurred 10 tive when the patient noted pain at the posterior or deep aspect of months after the primary surgery because of epilepsy. The bony the shoulder on forced external rotation at 90 abduction of the block was broken, resulting in shoulder pain and recurrent disloca- shoulder. Second, posterior capsular tightness was evaluated on ex- tion. At 19 months after the primary surgery, he underwent revision amination under general anesthesia and arthroscopy as a gold stan- surgery. The iliac bone was fixed at the glenoid, and the Bankart re- dard. The arthroscopic finding, during which the posterior capsule pair was added. At 36 months of follow-up, the JSS-SIS was 80, and and the posterior bundle of the inferior glenohumeral ligament dislocation had not occurred. The Bristow procedure has shown were checked for their elasticity and presence of pathologic fibrotic a relatively lower rate of postoperative dislocation or subluxation. changes, was the diagnostic criteria for posterior capsular tightness. Dislocations that occurred were accompanied by screw and/or Then, the efficacy of 2 tests was investigated. Posterior capsular bone block migration, and so revision surgery was difficult. We sug- tightness was positive in 46 shoulders and negative in 11. The sen- gested an anterior bony structure was necessary to prevent further sitivity, specificity, accuracy, positive predictive value, and negative anterior dislocation in the revision surgery after a failed Bristow pro- predictive value of the FIR tests were 85%, 100%, 88%, 100%, and cedure. Reconstruction of the anterior bony structure led to our suc- 61%, and those of ABER tests were 76%, 73%, 75%, 92%, and cessful results. Two patients who underwent revision surgery after 42%, respectively. Furthermore, the results of those tests showed Bristow procedure were assessed. No subluxation or dislocation oc- a significant relationship with the presence of tightness. In conclu- curred that required repeated reconstruct of the broken anterior sion, these 2 new tests were effective for the detection of posterior bony structure. capsular tightness.

89 A case report of recurrence after Oudard-Iwahara 87 Arthroscopic repair for recurrent anterior dislocation of procedure for recurrent anterior dislocation the shoulder of middle aged and older patients associated with MIYOSHI Naokia, IRIE Torua, TOGIYA Satoshia, MATSUNO Takeoa, massive rotator cuff tear: A report of two cases b a a b c a USHIROYAMA Tsunenori , Department of Orthopaedic Surgery, SANO Sakae , FUJITA Koji , ISHIGE Noriyuki , Department of Or- Asahikawa Medical College; bDepartment Orthopaedic Surgery, thopaedic Surgery, Matsudo Municipal Hospital; bJFE Kawatetsu c Sapporo Aiiku Hospital Chiba Hospital; Matsudo Orthopaedic Hospital We reported a case of recurrence after Oudard-Iwahara proce- The purpose of this report is to present 2 patients (middle-aged dure for recurrent anterior dislocation that was performed approx- and older) who underwent simultaneous arthroscopic rotator cuff imately 20 years ago. A 56-year-old man sustained a recurrent and Bankart repair for recurrent dislocations of the shoulder associ- dislocation of his right shoulder after a traffic accident and re- ated with massive rotator cuff tear. Patient 1 was a 58-year-old ceived shoulder stabilization procedure when he was 30 years woman whose shoulder first dislocated when she fell off her bicycle old. After the operation, his shoulder range of motion (ROM) at age 57. After more than 5 dislocations, she underwent an arthro- was restricted, but his shoulder apprehension disappeared. scopic Bankart and capsular and rotator cuff repair. The postopera- When he was 50 years old, he hit his right shoulder against a col- tive range of motion (ROM) at 1 year was flexion, 170; abduction, league, and his shoulder apprehension relapsed. After that, his 170 ; and external rotation, 60 . Patient 2 was a 74-year-old shoulder apprehension increased gradually, so he consulted us in woman whose first shoulder dislocation occurred when she fell in March 2004. His shoulder ROM was restricted to120 flexion, the bathroom at age 74. After more than 10 dislocations, she under- 110 abduction, and 30 2nd external rotation. Anterior appre- went an arthroscopic Bankart and biceps tendon and rotator cuff re- hension sign and relocation test were positive. The radiographs re- pair including subscapularis repair. The postoperative ROM at 1 vealed the grafted bone, which was continued to the coracoid year was flexion, 160; abduction, 145; and external rotation, process, and computed tomography and magnetic resonance ar- 45 . Although more cases and longer-term assessments will be thrography revealed anterior labral injury. We performed an ar- needed, it is possible that simultaneous arthroscopic anatomic re- throscopic Bankart repair in August 2004. Three years after the pair including rotator cuff repair will lead to better clinical results operation, his shoulder apprehension had disappeared. His shoul- without obvious complications. der ROM was 150 flexion, 180 abduction, and 65 2nd exter- nal rotation. The patient returned to work. Reports of a recurrence after Oudard-Iwahara procedure are rare. The factor related to recurrence was bone resorption of the grafted bone, but in this case, bone resorption was not clear. We thought the causes 88 Revision surgery after a Bristow procedure of recurrence in this patient were Bankart lesion, decrease of vol- NAKAMURA Shinichiroa, NAKAGAWA Yasuakia, KOBAYASHI ume of the subscapularis muscle, and change of the position of Masahikoa, NAKAMURA Takashia, SUZUKI Takashib, aDepartment the conjoined tendon. We thought that the main cause of this of Orthopaedic Surgery, Kyoto University Hospital; bDepartment of case was Bankart lesion, so we performed the Bankart repair. In Orthopaedic Surgery, Osaka Red Cross Hospital addition, because of the existence of grafted bone, we thought Various surgical procedures have been proposed for recurrent open technique would be difficult, so we performed arthroscopic dislocation. The Bristow procedure is a nonanatomic repair of the Bankart repair. The follow-up period of this case is short, but satis- anterior structure. However, it has shown a relatively lower rate of factory results were obtained. e22 Abstracts J Shoulder Elbow Surg

90 Arthroscopic treatment for bilateral recurrent shoulder Although the cause of this disease could not be cured, the midterm anterior subluxations in a patient with Ehlers-Danlos syndrome: period clinical results of total shoulder arthroplasty are excellent. A case report SUGIHARA Takayukia, NAKAGAWA Teruhikob, HIRATSUKA Kentaroc, MUNETA Takeshic, SHINOMIYA Kenichic, aDepartment of Orthopaedic Surgery, Mishima Social Insurance Hospital; bDepartment of Orthopaedic Surgery, Doai Memorial Hospital; c 93 The arthroscopic decompression for suprascapular nerve Department of Orthopaedic Surgery, Tokyo Medical and Dental palsy by a ganglion of the scapular region University TAJIMA Yoshitakaa, NAKAGAWA Teruhikoa, TSUCHIYA Masami- Ehlers-Danlos syndrome is characterized by hypermobility of tua, WAKABASHI Yoshiakib, MUNETA Takeshib, SHINOMIYA Ken- the joints and hyperextensibility of the skin. The purpose of this nichib, aDepartment of Orthopaedic Surgery, Doai Memorial study was to report a 16-year-old boy with Ehlers-Danlos syndrome Hospital; bDepartment of Orthopaedic Surgery, Tokyo Medical who was treated by arthroscopic surgery for bilateral recurrent and Dental University shoulder anterior subluxations. The patient visited our hospital com- The purpose of this study was to report the results of arthroscopic plaining of anterior instability of his bilateral glenohumeral joint on decompression of ganglion cysts causing suprascapular nerve August 13, 2004. His right shoulder joint subluxated anteriorly at palsy. Four shoulders with suprascapular nerve palsy by ganglion the age of 14. His left shoulder joint subluxated anteriorly at the cyst were evaluated. One was a professional baseball player. All age of 15. The subluxations of the bilateral shoulder joints had oc- patients had shoulder pain, weakness on external rotation, and atro- curred recurrently since then. Arthroscopic surgery was performed phy of the infraspinatus muscles. Magnetic resonance images (MRIs) on his right shoulder on December 14, 2004, and on his left shoul- showed large cystic lesions adjacent to the supraglenoid notches. der on August 16, 2005. The anterior labrum was attached to the Posterior labrum fraying was seen in 3 shoulders. The symptoms glenoid rim by suture anchors. For 2 years after the operation, nei- (shoulder pain, weakness of muscle strength) recovered in all pa- ther shoulder showed any subluxation. Apprehension tests were tients. Postoperative MRIs showed the cysts had disappeared, and negative for both shoulders. The prognosis after the operation is no recurrences were found in follow-up MRIs. There is a risk of nerve good. damage, but we think this procedure is a useful method.

91 Arthroscopic release for shoulder internal rotation 94 The clinical results of primary arthroscopic Bankart repair contracture secondary to brachial plexus birth palsy a a a for athletes with initial traumatic anterior shoulder dislocation SAISU Takashi , KAMEGAYA Makoto , KENMOKU Tomonori , SU- SUZUKI Kazuhide, TSUTSUI Hiroaki, MIHARA Kenichi, MAKIUCHI GAYA Hiroyukib, MORIISHI Jojib, aDivision of Orthopaedic Surgery, b Daisuke, NISHINAKA Naoya, Department of Orthopaedic Surgery, Chiba Children’s Hospital; Funabashi Orthopaedic Hospital Showa University Fujigaoka Rehabilitation Hospital We tried arthroscopic release of the subscapularis tendon for 2 The purpose of this study was to evaluate the short-term results of children with internal rotation contracture due to brachial plexus arthroscopic Bankart repair using a suture anchor device in athletes birth palsy. The patients were a 7-year-old boy and an 8-year-old withinitial traumatic anterior dislocation of the shoulder. Weretrospec- girl. Follow-up terms were 12 months and 6 months, respectively. tively studied 13 athletes (12 men, 1 woman) who were an average Preoperative and postoperative ranges of motion and patient satis- age of 20.5 years (range, 16-25 years). The mean term from initial dis- faction were investigated. Maximum range of external rotation in location to operation was 18.8 days (range, 5-32 days). The mean fol- the 90 shoulder flexion position had improved by 20 for the boy low-up after surgery was at 20.5 months (range 4-53 months). We and 15 for the girl. The boy was satisfied with relief from difficulty performed arthroscopic Bankart repair for 5 shoulders using an aver- in sustaining the shoulder elevation position, and the girl was satis- age of 3.6 (range 2-4) Panalok suture anchors, and for 8 shoulders, fied with a sense of relaxation in the anterior part of the shoulder. Al- 3.1 (range, 2-4) Panalok loop anchors to which 1 more suture was though there was a little benefit of this surgical technique, it was added (1 anchor–2 sutures method). We evaluated the rate of return a less invasive procedure than established procedures such as exter- to preoperative sports activities and the rate of recurrences after sur- nal rotation osteotomy of the humerus or Gilbert’s procedure of open gery. The clinical evaluations were performed using the Japan Shoul- subscapularis muscle release. der Society shoulder instability score (JSS-SIS) and Rowe score. All patients returned to their preoperative sports level at an average 4.8 months (range, 3-8 months). At the time of the last investigation, the av- erage JSS-SIS was 97.9 points (range, 86-100), the average Rowe score was 97.7 points (range, 90-100), and all of the patients had 92 Osteoarthritis of the shoulder derived from alkaptonuria: a rating of excellent. The short-term results of arthroscopic Bankart re- A case report pair for athletes with initial traumatic anterior shoulder dislocation was SAITA Hikaru, SHIBATAYozo, IZAKI Teruaki, SHINODA Tsuyosi, TER- satisfactory. It is important to do primary repair in young athletes with ATANI Takeshi, KAMADA Satoshi, NAITO Masatoshi, Department a first-time traumatic anterior shoulder dislocation. of Orthopaedic Surgery, Fukuoka University Faculty of Medicine A 50-year-old man visited our clinic due to bilateral shoulder pain and left knee pain. Black-brown pigmentations were observed on the conjunctiva bulbi and the auricle. Plain x-ray films showed se- vere osteoarthritic changes of both shoulders. Ranges of motion of 95 Examination of the functional problem in cases with the shoulder were 100 of flexion in the right shoulder, 80 in the recurrent anterior dislocation of the shoulder joint left shoulder, 15 of external rotation in the right shoulder, 0 in TSUTSUI Hiroaki, MIHARA Kenichi, SUZUKI Kazuhide, MAKIUCHI the left, and fourth lumbar vertebra of internal rotation in both shoul- Daisuke, Department of Orthopaedic Surgery, Showa University Fu- ders. The preoperative Japanese Orthopaedic Association (JOA) jigaoka Rehabilitation Hospital scores were 55 points in the right shoulder and 78.5 points in the The exercise cure considered to be required for anterior disloca- left. Total shoulder arthroplasties were performed on the bilateral tion of shoulder joint is an improvement of the function of the shoul- shoulders. The postoperative JOA scores were 90.5 points in the der joint for avoiding reduction in which the humeral head deviates right shoulder at 55 months and 91 points in the left at 62 months. from the glenoid cavity when external force is added. This J Shoulder Elbow Surg Abstracts e23

presentation reports the functional problems that were related with This study investigated characteristics of recurrent anterior sub- shoulder joint stability as determined from the x-ray examinations luxation or dislocation of the shoulder with a partial thickness tear in 23 patients (21 men, 2 women) who underwent scopic Bankart of the rotator cuff. We reviewed presurgery medical histories and repair. Their averaged age was 26.4 6 9.6 years. The functions clinical results of 81 shoulders of 81 consecutive patients who had of the rotator cuff and scapula were examined in the Scapula-45 undergone surgery for recurrent anterior subluxation or dislocation x-ray examination. Next, with the arm at the side and maximum el- of the shoulder. Of 81 shoulders, arthrography and magnetic reso- evation, the x-ray image was used to examine the mobility of the nance imaging was used to diagnose 25 preoperatively as partial clavicle and thorax. Finally, x-ray images of maximum elevation thickness tears of the rotator cuff. We divided the shoulders into 2 were used to examine the angle of shoulder abduction and the groups according to whether the partial thickness cuff tear was com- height. Dysfunction of the rotator cuff was 53.9%, and dysfunction plicated or not. The differences between the 2 groups were tested for of the upper rotation of the scapula was 76.9%. Decreased mobility statistical significance for age at surgery, sex, dominant side, dura- of the thorax was 52.2%, and 60.9% demonstrated immobility of el- tion from trauma to surgery, the number of dislocations, whether dis- evation of the clavicle. The angle of maximum elevation was de- location or subluxation, the size of Hill-Sachs lesion and Bankart creased about 5 compared with the opposite side. Although lesion, the scores of clinical results, and muscle strength after surgery about half the patients had dysfunction of the rotator cuff, a large using Biodex. Shoulders with partial thickness tears had a signifi- number of dysfunctions of the scapula, clavicle, and thorax were cantly more frequent history of dislocation compared with other found. The exercise cure to raise these motor functions is required shoulders (P < .05). Furthermore, shoulders with partial thickness to prevent recurrence. tear had significantly larger Hill-Sachs lesion than other shoulders (P < .05). The muscle strength of extension 6 months after surgery was significantly less in shoulders with partial thickness tears, but no significant difference was found 1 year after surgery. Remaining factors showed no significant differences between groups. For 96 Traumatic anterior glenohumeral instability accompanied a safe return to sports activities, attention must be given to reduced with superior labrum anterior and posterior lesions muscle strength at 6 months after surgery in shoulders with partial OZEKI Nobutake, YAMAZAKI Tetsuya, UCHIDA Yoshihiro, AKEDA cuff tears. Masaki, Department of Sports Medicine, Yokohama Minami Kyosai Hospital The purpose of this study was to evaluate the arthroscopic find- ings in shoulders with superior labrum anterior and posterior (SLAP) lesions combined with traumatic anterior glenohumeral instability. 98 Arthroscopic Bankart repair for traumatic anterior Investigated were 118 shoulders in 118 patients (100 men, 18 instability of shoulder joint—indication for high-demand patients women) who underwent arthroscopic surgery for anterior gleno- NAGATA Yoshihiko, MOCHIZUKI Yu, YOKOYA Shin, OCHI Mit- humeral instability. The mean age at surgery was 21.7 years. Ar- suo, Department of Orthopaedic Surgery, Hiroshima University, throscopic findings were evaluated concerning the type of SLAP Graduate School of Biomedical Sciences lesions, pathology of glenohumeral instability, properties of the an- Arthroscopic Bankart repair with suture anchors has been terior inferior glenohumeral ligament (AIGHL) and the middle gleno- thought not to be suitable for high-demand patients. The purpose humeral ligament (MGHL), and the presence of Hill-Sachs lesion. of this study was to compare the results of arthroscopic Bankart re- Obvious detachment of the superior labrum was noted in 37 pa- pair using suture anchors in traumatic anterior glenohumeral insta- tients (S group), and the other 81 shoulders were the N group. There bility between high-demand patients and non–high-demand were no significant differences between the 2 groups for age, sex, patients. Seventy-four patients (74 shoulders) with traumatic unilat- number of dislocations, or the type of sports activity. Among the S eral anterior shoulder instability were evaluated using the Rowe group, superior labrum lesions were classified as type II in 31 score, rate of recurrence, and range of motion at an average 38 and type II and III in 6 shoulders according to Snyder’s classifica- months after arthroscopic surgery. Of the 74 patients, 45 (45 shoul- tion, and 33 had a continuation with Bankart lesion. The pathology ders) were high-demand patients, participating in judo, karate, box- of glenohumeral instability was classified according to Kumagai’s ing, wakeboarding, snowboarding, basketball, handball, baseball, classification, and ligament–labrum complex detachment type or rugby. In the 45 high-demand patients, the average Rowe score was seen in 26 shoulders, small bony fragment type in 10, and gle- improved from 30.2 to 92.4 points and was not statistically different noid bony defect type in 1. The AIGHL was found well developed in from that in non–high-demand patients (from 31.5 to 90.6 points). 25 and poorly defined in 12. The MGHL was detected in 28 shoul- The high-demand patients had lost a mean of 4 of external rotation ders, including 5 with cord-like MGHL. Among the N group, the in abduction, and this was not statistically different from that in non– AIGHL was poorly defined in 63, and the MGHL was absent in high-demand patients (3 external rotation). There was no signifi- 39. Anterior glenohumeral instability with detachment of the supe- cant difference between the recurrence rate in the high-demand pa- rior labrum likely had well developed AIGHL and continuation tients (2 of 45, 4.4%) and that in non–high-demand patients (1 of with Bankart lesion. According to these results, we hypothesized 29, 3.4%). All patients returned to their respective sports at the that traumatic traction force during shoulder dislocation might ex- same level. Arthroscopic stabilization is as reliable a procedure in tend the Bankart lesion superiorly. high-demand patients as it is in non–high-demand patients.

97 Analysis of recurrent anterior subluxation or dislocation of 99 The results of our modification of Bristow procedure the shoulder with partial thickness tears of the rotator cuff KURODA Shigehito, ISHIGE Noriyuki, MIKASA Motohiko, MAR- NAKAMURA Koichia, HATA Yukihikoa, ISHIGAKI Norioa, MURA- UTA Kimiko, Matsudo Orthopaedic Hospital KAMI Narumichib, KOBAYASHI Hirokazuc, ITSUBO Toshirod, We wished to report the results of our modification of Bristow pro- UCHIYAMA Shigeharud, KATO Hiroyukid, aDivision of Rehabilita- cedure, in which the coracoid process is transferred to the anteroin- tion, Shinshu University School of Medicine; bAizawa Hospital ferior glenoid rim to extend the glenoid. We investigated 203 joints Sports Medicine Center; cDepartment of Orthopaedic Surgery, (44 women, 159 men) that were followed up for more than 5 years Chushin Matsumoto Hospital; dDepartment of Orthopaedic Surgery, after surgery. Patients were a mean age of 25.3 years at the surgery. Shinshu University School of Medicine The mean follow-up was 7 years and 10 months. No recurrence of e24 Abstracts J Shoulder Elbow Surg

dislocation was reported. The mean external rotation with arm at dislocation, operative repair was undertaken. Under general anesthe- side after surgery was 45.6. The mean Japan Shoulder Society sia, open reduction of the dislocation was performed, and the humeral shoulder instability score was 55.8 before surgery and 93.4 after shaft–humeral head fracture was treated with internal fixation with surgery. Screw breakage occurred in 4 shoulders. Slight deformity plate and screws. The fractures and dislocation healed without any of the humeral head was recognized in 4 shoulders. The sports re- problems at 6 to 12 months postoperatively. At final follow-up, the pa- turn was as follows (parenthesis show patients in overhead sports tient had returned to work and regained normal mobility. whose dominant side was affected): full return, 63% (36.4%); level down, 23.9% (36.4%); changed sports, 8.7% (13.6%); stopped playing, 4.4% (13.6%). No recurrence, easy procedure, wide ap- plication, and minimal complication were the most important results 102 Classification and treatment of proximal humeral of the surgery for recurrent dislocation. Our modification of the Bris- fractures: An analysis of the JSS Database—Part one: Classification tow procedure permits a wide view of the glenohumeral joint, and a b b we were able to transfer the coracoid process to the best position TAMAI Kazuya , ISHIGE Noriyuki , KURODA Shigeto , OHNO Watarua, ITOH Hiromotoc, HASHIGUCHI Hiroshic, IIZAWA Norish- of the glenoid with the best direction. The operation could be fin- c b a ished within 45 minutes. Full return to the overhead sports was ige , MIKASA Motohiko , Department of Orthopaedic Surgery, Dokkyo Medical University; bMatsudo Orthopaedic Hospital; only 36.4% in cases affecting the dominant hand, which is a limita- c tion of this procedure. No recurrence was recognized, and the re- Department of Orthopaedic Surgery, Nippon Medical School sults of our method were satisfactory. With the aim to clarify the fracture patterns of proximal humeral fractures and to reevaluate the validity of using the revised Neer clas- sification (2002), we analyzed 668 patients (174 men, 494 women) who had been treated by 18 active members of the Japan Shoulder Society (JSS database). Mean patient age was 63.4 years. We found that all the fractures of the JSS database, with the 100 Osteoarthrosis before and after the Bankart operation exception of articular surface injuries, fell under one of the fracture for traumatic anterior shoulder instability: Analysis at five to patterns provided by Codman (1934). When the revised Neer clas- twenty years’ follow-up sification was applied, we found that 654 of the 668 fractures (98%) a b c YOSHIDA Atsushi , OGAWA Kiyohisa , IKEGAMI Hiroyasu ,UI had an appropriate category in this classification, including 19 c a Michimasa , Department of Orthopaedic Surgery, Saitama Na- (2.8%) with valgus impacted fracture. Those that could not be clas- b c tional Hospital; Department of Sports Clinic and Department of sified with the revised Neer classification (2%) were ‘‘3-part’’ with Orthopaedic Surgery, Keio University School of Medicine a complete anatomic neck fracture. We concluded as follows: (1) Weinvestigated 163 patients (167 shoulders) with the Bankart op- proximal humeral fractures, excluding articular surface fractures, oc- eration for presence of osteoarthrosis by preoperative computed to- cur along the original epiphyseal lines; (2) the revised Neer classifi- mography (CT) and XP, and postoperative XP at follow-up. The cation covers 98% of all proximal humeral fractures, and it would be causes of the osteoarthrosis were analyzed by ages, periods, number appropriate to use this classification in a clinical practice; and (3) of recurrent dislocations, size of bone defect of anterior glenoid, and when there are 3 displaced segments, close attention should be restriction of ranges of motion. The average age was 18 years (range, paid to the fracture line on the anatomic neck. If the fracture spans 7-29 years) at the first dislocation, 22 years (range, 14-34 years) at along the full length of the anatomic neck, it is not included in the re- operation, and was 31years (range, 21-42 years) at follow-up. Osteo- vised Neer classification and is highly likely to be a fracture type that arthrosis existed in 44 shoulders by preoperative CT, which included involves a high risk of humeral head necrosis. 12 shoulders (7.2%) by preoperative XP,and in 30 shoulders by post- operative XP. The 167 shoulders were classified into the following 5 groups: postoperative occurrence group, which were only detected by postoperative XP, 6 shoulders; progress group, which were de- 103 Classification and treatment of proximal humeral tected by preoperative CTand postoperative XP,12; preoperative oc- fractures: An analysis of the JSS Database—Part two: Treatment currence group, which were detected by preoperative CTand XP,and TAMAI Kazuyaa, HASHIGUCHI Hiroshib, IIZAWA Norishigeb, postoperative XP, 12; nonprogress group, which were only detected ITOH Hiromotob, ISHIGE Noriyukic, KURODA Shigetoc, OHNO by preoperative CT, 20; and nonoccurrence group, 117. Statistical Watarua, MIKASA Motohikoc, aDepartment of Orthopaedic analysis showed 30 shoulders with osteoarthrosis by postoperative Surgery, Dokkyo Medical University; bDepartment of Orthopaedic XP had more frequent preoperative dislocations and large bone de- Surgery, Nippon Medical School; cMatsudo Orthopaedic Hospital fects than the remaining 137 shoulders. Osteoarthrosis developed With the aim to clarify the prognostic factors that may affect the postoperatively had a low rate of 4.9% (6 of 167) and was related treatment results of proximal humeral fractures, we retrospectively an- to the preoperative large number of recurrent dislocations and large alyzed 687 cases registered to the Japan Shoulder Society (JSS) data- bone defects. It is thought that a basic cause of the osteoarthrosis is base. In this study, the active elevation of the shoulder was used as an in the preoperative condition. Although the Bankart operation could indicator of the functional outcome, with 150 or more as being excel- not prevent development of osteoarthrosis, the operation itself may lent, 90 to 150 as being fair, and less than 90 as being poor. Of the not promote progress of osteoarthrosis. 183 one-part fractures, 24 (13%) showed a poor result. Particularly, the result of 18 of the 88 (20%) that had a fracture line in the surgical neck proved to be poor. The risk factors for the poor outcome included the age of the patient, comorbidity such as dementia, and a varus de- 101 Fracture of the humeral shaft associated with ipsilateral formityat the surgical neck(neck–shaft angle < 120). Of the 126 two- fracture–dislocation of the shoulder: A report of a case part surgical neck fractures, 21 (17%) showed a poor result, with age, SUMIURA Seiji, Department of Orthopaedic Surgery, Shakaihoken comorbidity,and varus deformity being risk factors. Of the 47 two-part Tokuyama Chuo Hospital greater tuberosity fractures, only 2 (4%) showed a poor result. Of the Shoulder fracture–dislocation associated with the ipsilateral hu- 73 three- and 4-part fractures, 22 (30%) showed a poor result, with meral shaft fracture is an uncommon combination. We reported age and persisting displacement of tuberosities as risk factors. Hemi- a case of anterior shoulder fracture–dislocation and ipsilateral fracture arthroplasty had been performed in 21 three- and 4-part fractures, of the shaft of the humerus. A 37-year-old man sustained a motorcycle of which 19 (90%) resulted in a poor outcome. We would like to em- accident that resulted in deformity and painful swelling of the left shoul- phasize that varus deformity of the surgical neck and the poor reduc- der and arm. No neurovascular deficit was found, and all other clini- tion or repeat displacement of the tuberosities should be avoided to cal findings were normal. After failure of closed reduction of the obtain better functional results in treating proximal humeral fractures.