33Rd Annual Meeting of the Japan Shoulder Society

33RD ANNUAL MEETING OF THE JAPAN SHOULDER SOCIETY

001 An Anatomical Study of the Subscapularis Insertion to the sis of the tendon in the articular side were significantly higher in both Humerus mature (p ¼ 0.02) and aged (p ¼ 0.014) rabbits. However, the sta- Tokiyoshi Akinari, Ide Junji, Hirose Jun, Mizuta Hiroshi, Department tistical trend, in which the collagen synthesis of the articular side de- of Orthopaedic Surgery, Graduate School of Medical Sciences, creased with age, was observed (p ¼ 0.058). The collagen Kumamoto University synthesis of the tendon in the articular side was significantly higher Recently many rotator cuff tears including subscapularis are re- regardless of age. A more active turn over of collagen might be repaired arthroscopically. However, there are only a few reports about quired for the tendon in the articular side. The decrease of collagen the morphology of the subsccapularis muscle insertion to the hu- synthesis of the tendon on the articular side with age might induce merus. The knowledge of the insertion morphology leads to appreci- the degeneration of a rotator cuff tendon from the articular side, re- ate the tear size and to repair anatomically. In this study, we sulting in an articular side tear. investigated the cadaveric shoulders to clarify the morphology of the subscapularis muscle insertion and the difference between sexes and sides. We investigated 24 cadaveric shoulders (bilateral shoulders of five males and seven females; mean age 87 years old) and 003 Gene Expression after Administration of TGF-b1 on Cells measured the maximum longitudinal distance (proximal-to-distal di- Derived from the Rotator Cuff rection) and transverse distance (medial-to-lateral direction) of the Yamaguchi Hiroshi, Department of Orthopaedic Surgery, The subscapularis insertion. We also measured the distance between University of Ryukyus School of Medicine the articular cartilage edge and the most medial tendon insertion Suenaga Naoki, Minami Akio, Department of Orthopaedic Sur- (bare area) at sites of the proximal end, maximum transverse dis- gery, Hokkaido University School of Medicine tance position and the distal end. The data were analyzed with an Sonnabend David H, Department of Orthopaedic and Trauma unpaired-t-test or paired-t-test between sexes and sides. Statistical sig- Surgery, Royal North Shore Hospital, The University of Sydney nificance was set at p < 0.05. The subscapularis muscle insertion Although good mid-term clinical results after a rotator cuff repair was consisted of 2 parts, proximal tendinous part and distal muscular have been reported on, it was pointed out that complete tendon re- part in all cadavers. The mean maximum longitudinal distance of the attachment to the humerus is very difficult. The aim of the present tendon insertion was 35.5 (SD, 4.2) mm. The mean transverse dis- study was to investigate the effect of TGF-b1 on a sheep infraspinatus tance of the tendon insertion was 15.8 (SD, 2.3) mm. The mean dis- tendon cell cultured on Polyglactin910. The cells derived from tance of the bare area at sites of the proximal end, maximum a sheep infraspinatus tendon by an enzyme digestion method transverse distance position and the distal end was 3.1 (SD, 2.0) were cultured for 10 days. mm, 5.9 (SD, 1.7) mm, 11.9 (SD, 3.4) mm, respectively. Significant After the culture, expression of genes were investigated by RT- differences existed between sexes in maximum transverse distance PCR methods after the extraction of RNA with TRIzole treatment. (p ¼ 0.0006), the bare area at the maximum transverse distance po- Evaluated genes were type 1 and 3 collagen, MMP-1 and MMP- sition (p ¼ 0.00199) and distal end position (p ¼ 0.0015). No sig- 13, Aggrecan, Biglycan, Decorin, Fibromodulin, Lumican, Elastin, nificant differences were found between sides in all subjects. We Osteopontin. Statical comparisons were performed using one-way examined the subscapularis insertion to the humerus in cadaveric analysis of variance and Fisher PLSD tests. Differences were consid- shoulders. Anatomical measurements in this study may be useful in ered significant for less than 5%. In results, mRNA expression was evaluating and reattaching the subscapularis to the humerus. significantly increased for type 1 collagen, Aggrecan, Elastin. Espe- cially, type 1 collagen, Elastin were revealed a dose dependent positive effect. mRNA expression was, however, significantly decreased for MMP-1, Lumican. 002 Aging Induces Less Collagen Synthesis on the These results indicated that TGF-b1 may have a significant effect Supraspinatus Tendon in the Rabbit on rotator cuff healing and stimulus for further studies in this field. Takahashi Norimasa, Department of Orthopaedic surgery, Kohno- dai Hospital, National Center of Neurology and Psychiatry, SANO Sakae, Matsudo City Hospital Ochiai Nobuyasu, Department of Orthopaedics, University of Cali- 004 Behavior of Host and Graft Cells in Early Remodeling fornia, San Diego Process After Tendon Transplantation For The Rotator Cuff Saisu Takashi, Chiba Children’s Hospital Defect Moriishi Joji, Funabashi Orthopaedic Sports Medicine Center Iwata Yoshio, Morihara Toru, Tachiiri Hisakazu, Fujiwara Hiroyoshi, Because of the poor vascularity of the supraspinatus tendon in Kubo Toshikazu, Department of Orthopaedics, Graduate School of the articular side, the degeneration of the tendon was considered Medical Science, Kyoto Prefectural University of Medicine to start from the articular side. To understand the pathology of a rota- Horii Motoyuki, Department of Orthopaedic Surgery, Kyoto Interdis- tor cuff tear, we assessed the effect of aging on the collagen synthe- ciplinary Institute Hospital of Community Medicine sis of the tenocyte in supraspinatus tendon in the rabbit. 12 New Kurokawa Masao, Department of Orthopaedic Surgery, Saiseikai Zeeland white rabbits were used, which included 6 mature rabbits Suita Hospital aged 1 year old and 6 aged rabbits aged 4-5 year old. After their The purpose of this study is to examine the behavior of the host sacrifice, the supraspinatus tendons were harvested immediately and graft cells in early remodeling process after tendon implantation and trimmed to the rectangular shape of 4 mm x 8 mm. They were to the defect using green fluorescent protein (GFP) transgenic rat. 20 divided into two pieces, which included the articular side surface Sprague Dawley (SD) rats and 20 green fluorescent protein (GFP) and the bursal side surface. They were placed in to cell culture me- transgenic rats were used in this study. Tendinous defect were dia containing [3H]-proloine (5 mci/ml of media) and incubated at made close to the supraspinatus tendon insertion. In group A, the 37C for 48 hours. Following incubation, [3H]-hydroxyproline (col- Achilles tendons of SD rats were transplanted into the defect of lagen synthesis) was quantified by HPLC after acid hydrolysis. The GFP rats. In group B, the Achilles tendons of GFP rats were trans- data were compared to each group using t-test. The collagen synthe- planted into the defect of SD rats. At 0,1,3,7 and 28 days after

e1 e2 Abstracts J Shoulder Elbow Surg

surgery, sections stained with hematoxylin and eosin were assessed 6 0.88, massive: -1.66 respectively. The smaller difference be- histologically, and localization of GFP positive cells were also eval- tween superficial tears and deep tears with delamination were ob- uated. The graft was surrounded by inflammatory cells at 3 days. At served in the larger sizes of superficial tears. The smaller the bone-tendon insertion, fibroblastic cells started to infiltrate histo- difference between superficial tears and deep tears with delamina- logically and increased in number in 28 days. In Group A, a small tion were observed in the larger sizes of superficial tears. number of signal positive host cells were found around both the bursal and articular side of grafted tendon at 1 day. The host cells increased at 7 days. In Group B, signal positive graft cells were found in the graft at 1 day, which decreased over time. Replacement 011 Optimal Humerus Positioning when Evaluating Rotator of graft cells by host cells occurred in the early remodeling process. Cuff Tear on MRI Infiltrated host cells to both the bursal and articular side play an im- Matsuura Koumei, Ishitani Eiichi, Department of Orthopaedic Sur- portant role in the early remodeling process after tendon implanta- gery, Kitakyushu Municipal Wakamatsu Hospital tion for a defect of the rotator cuff. The optimal position of the humerus when evaluating rotator cuff tears on MRI has yet to be determined. Obtaining a reproducible MR view without individual differences is important but it is sometimes difficult because the inclination of the scapulars are different. We de- 009 The Usefulness of Helical Computed Tomography with fined the ideal position of the humerus during MRI as follows: 1. Arthrography for the Evaluation of the Delamination of the Supraspinatus muscle runs straight and is parallel to the scapular Rotator Cuff Tear plane. The center of the insertion of the supraspinatus tendon was Fujii Yasunari, The Health Service Center, National Institute of Fit- nearly at the border between the superior and inferior facets (S/M ness and Sports in Kanoya border). We rotated the humerus so that the scapular plane was par- Togo Yasuhisa, Fukushima Kaori, Kakoi Hironori, Ogura Tadashi, allel to the S/M line. The S/M angle was defined as the angle be- Koshinkai Ogura Memorial Hospital tween two lines drawn from the center of the humeral head to S/ The purpose of this study was to show the usefulness of the recon- M border and to the bicipital groove. We defined q a the angle be- structed coronal and sagittal views after an arthrographic helical tween the scapular plane and the horizontal plane, and b as the an- computed tomography (HCTA) to perform the minute evaluation of gle made by the line drawn from the center to the bicipital groove the delamination of the rotator cuff tear (RCT). Our subjects consisted and the axis of the flexed forearm. The internal rotation angle of of 32 shoulders of 31 cases with RCT, 22 men and 9 women with the humerus was caluculated as q + S/M angle + b – 90. Each facet a mean age of 55.0 years old. They were classified into the follow- on MR view was investigated. The S/M angle of 50 shoulders con- ing 3 groups according to their tear size; small tear (9 subjects), me- verged at 45.4. q of 140 shoulders varied. b was 15.2. The inter- dium tear (8 subjects), and large tear (15 subjects). We assessed the nal rotation angle was expressed as q- 30, mean 15. Each facet size and position of the delamination of the RCT with HCTA, and was easy to evaluate. Rotating the humerus so that the scapula plane their relation to age and size of the RCT. A delamination was ex- ran at S/M border 45to the bicipital groove produces high quality hibited in the 20 subjects of 32 (62.5%) with a mean age of 58.0 images. years old. The group with a delamination was older than that without a delamination with a mean age of 50.1 years old. As to the size of the RCT, a delamination was found in 2 of the 9 small tear subjects (22%), all 8 medium tear subjects, and 10 of the 15 large tear sub- 020 Anatomical Study for the Chondral Lesion of the jects (67%). The evaluation of the sagittal image showed that the Glenohumeral Joint subjects with a wide delamination from the SSP to the ISP (59.3 Goto Hideyuki, Hisazaki Shinji, Horiuchi Osamu, Ota Shusuke, years old) were older than the others with only an SSP delamination Otsuka Takanobu, Department of Orthopaedic Surgery, Nagoya (52.0 years old). The HCTA was one of the most useful examinations City University Medical School for the preoperative minute evaluation of the size and position of the Sugimoto Katsumasa, Department of Orthpaedic Surgery, Meitetsu delamination of the RCT. Hospital We evaluated the chondral lesion of the glenohumeral joint among the elder population. In this study, 31 shoulders of 20cases (Male 17 cases, Female 14 cases) were evaluated for the macro- 010 Evaluation of Retracted Distance in Full-thickness Rotator scopic investigation. The mean age of the cases was 81.8 years Cuff Tears with Delamination by using an MR Arthrography old ranging from 54 to 103 years old. Before the evaluation, the ro- Naka Yoshifumi, Ito Yoichi, Nakao Yoshihiro, Manaka Tomoya, Na- tator cuff and joint capsule were released from the insertion. The ob- kamura Nobuyuki, Nakano Motohiro, Tomo Hiroyasu, Matsumoto served site was divided into superior, middle, central, and inferior Isshin, Takaoka Kunio, Department of Orthopaedic Surgery, Osaka part for the glenoid side, and greater tuberosity, anterosuperior, an- City University Graduate Medical School teroinferior, posterosuperior, posteroinferior and long head of the bi- Delamination is one of the horizontal tears combined with artic- ceps part for the humeral side. Macroscoic findings were evaluated ular side tears and bursal side tears observed in full-thickness rotator according to the cartilage grading system; Grade 0: normal, Grade cuff tears. However, this pathology is not well known about in detail. I: discolouration, Grade II: mild erosion, Grade III: erosion, Grade MR arthrography was reported by us to be an effective imaging pro- IV: ulceration, and Grade V: eburnation. There were 5 rotator cuff cedure for intra-articular lesions. The aim of this study was to inves- tears among the cases. For the glenoind side, the superior part tigate the characteristics of delamination by measurements of their showed normal in the most of the cases, but the inferior part showed sizes with MR arthrography. We retrospectively evaluated 43 pa- more than grade II in the most of the cases. The middle part ap- tients in which we observed delamination arthroscopically. Comput- peared normal in Grade III, but the central part showed Grade III erized measurements of the sizes of the superficial tears and the or Grade IV in most of the cases. For the humeral head side, the su- difference between superficial tears and deep tears were performed perior part showed Grade II to III and the inferior part showed using the method previously reported by Toyoda et al. We statisti- Grade 0 to II. The long head of the biceps part appeared in Grade cally analyzed correlations between superficial tear sizes and the III to IV. In general, it might be understood that a glenohumeral joint differences as well as patients’ age and the differernces. Thirty-seven arthritis is rare clinically, because it is not a weight- bearing joint. shoulders (86%) in 43 patients were eligible for evaluation by MR However, focal chondral lesions are often associated with rotator arthrography. There was no correlation between patients’ ages cuff tears and severe joint contracture. This study provided useful in- and the differences. The differences in each full-thickness tear sizes’ formation for an arthroscopic evaluation of chondral lesions of the group were small: 1.32 6 0.64, medium: 1.20 6 0.52, large: 0.37 glenohumeral joint. J Shoulder Elbow Surg Abstracts e3

021 Anatomy of the Subscapularis Tendon Insertion which the lesser tuberosity. These results suggested that the supraspinatus Stabilizes the Long Head of the Biceps Tendon tendon worked more efficiently as an abductor of the shoulder joint Arai Ryuzo, Sugaya Hiroyuki, Maeda Kazuhiko, Moriishi Jyoji, with the arm externally rotated than internal rotation. Funabashi Orthopaedic Sports Medicine Center Mochizuki Tomoyuki, Department of Orthopedic Surgery, Tokyo Medical and Dental University Matsuki Keisuke, Department of Orthopedic Surgery, Chosei Public 023 The layered structure of the rotator cuff is affected by the Hospital insertion pattern of the supraspinatus tendon. Akita Keiichi, Unit of Clinical Anatomy, Tokyo Medical and Dental Mochizuki Tomoyuki, Sugaya Hiroyuki, Maeda Kazuhiko, Matsuki University Graduate School Keisuke, Nakagawa Teruhiko, Muneta Takeshi, Akita Keiichi, De- The subscapularis tendon (SSC) insertion is one of the key struc- partment of Orthopedic Surgery, Tokyo Medical and Dental Univer- tures that stabilizes the LHB. The purpose of this study was to inves- sity, Funabashi Orthopaedic Sports Medicine Center, Unit of tigate the anatomy of the most superior portion of the SSC Clinical Anatomy, Graduate School, Tokyo Medical and Dental Uni- insertion and clarify the relation between the SSC insertion and versity, Department of Orthopedic Surgery, Chosei Public Hospital, the pathway of the LHB. 20 embalmed shoulder girdles of cadavers Department of Orthopedic Surgery, Douai Memorial Hospital were used in this study. After the acromion and the coradoid process The purpose of this study was to reveal the detailed layered struc- were cut off, connective tissues were carefully removed and the SSC ture of the rotator cuff with regard to the coraocuhumeral ligament insertion was observed. In 4 specimens, muscle fibers of the SSC by dissecting anatomical specimens of adult shoulders. Fifty three were carefully removed in water to observe the intramuscular ten- shoulders of thirty nine adult cadavers were used for this study. After dons of the subscapularis. The SSC inserted onto the medial portion resecting the acromion, connective tissue is carefully removed and and the superior surface of the lesser tuberosity. The most proximal layered structure of the rotator cuff on the superior portion of the insertion of the tendon, derived from the most proximal portion of greater tuberosity was observed macroscopically. The connective the intramuscular tendon, formed an anteromedial wall and stabi- tissue between the posterior edge of the coracoid process and the lized the LHB at a more proximal portion continuing from the bicip- rotator interval, which was not ligamentous tissues, was observed ital groove. Further, the most proximal insertion of the SSC extended and then recognized as the coracohumeral ligament by its pathway. superiorly and formed a thin tendinous slip, which attached to the The coracohumeral ligament splayed out the supraspinatus and in- fovea capitis of the humerus. Both of the most proximal insertion of fraspoinatus tendon. After removing both tendons, the coracohum- the SSC and the tendinous slip created the semitubular structure eral ligament was observed to fuse with underlying capsule and and lengthened a channel of the LHB proximally. These results sug- extended to the greater tuberosity. However in 20 out of 53 speci- gested that the most proximal portion of the SSC and the slip can re- mens, the superficial distribution of the coracohumeral ligament inforce the channel of the LHB which changes direction from the was restricted to the narrow region. In 11 out of 20 specimens, bicipital groove to the superior tubercle of the glenoid at this portion. the pectoralis minor tendon unusually run beyond the coracoid pro- Clinically, in shoulders with a SSC injury, repairing the most proxi- cess and disturbed development of the coracohumeral ligament. In mal portion of this tendon was important in terms of the LHB stability. other 9 specimens, the supraspinatus tendon was unusually inserted to the lesser tuberosity and interrupted the development of the coracohumeral ligament. This result suggests that the layered structure of the rotator cuff with regard to the coracohumeral ligament was affected by the insertion pattern of the supraspinatus tendon and the 022 Anatomical Investigation of the Supraspinatus Insertion pectoralis minor tendon. Maeda Kazuhiko, Sugaya Hiroyuki, Arai Ryuzo, Moriishi Joji, Funa- bashi Orthopedic Sports Medicine Center Mochizuki Tomoyuki, Yoshimura Hideya, Department of Orthopae- dic Surgery, Tokyo Medical and Dental University 024 The Infraspinatus is the Most Affected Tendon in the Matsuki Keisuke, Department of Orthopaedic Surgery, Chosei Rotator Cuff Tears public hospital Matsuki Keisuke, Department of Orthopaedic Surgery, Chosei Pub- Akita Keiichi, Unit of Clinical Anatomy, Graduate School, Tokyo lic Hospital Medical and Dental University Sugaya Hiroyuki, Maeda Kazuhiko, Moriishi Joji, Funabashi Ortho- It is generally believed that the supraspinatus tendon plays an im- paedic Sports Medicine Center portant role in the shoulder function. However, precise anatomy of Mochizuki Tomoyuki, Department of Orthopaedic Surgery, Tokyo the supraspinatus tendon has not been well described. The purpose Medical and Dental University of this study was to investigate the anatomy of the supraspinatus ten- Akita Keiichi, Unit of Clinical Anatomy, Graduate School, Tokyo don. 57 cadavers (103 shoulders) were used for this study. The clav- Medical and Dental University icle and humerus were cut off at their proximal parts. After resection The purpose of this study was to examine the anatomy of the in- of the acromion, the coracohumeral ligament was carefully re- fraspinatus including the orientation of muscle fibers and the inser- moved. In some specimens, the infraspinatus was completely re- tion to the greater tuberosity. Ninety-three shoulders from 52 moved from the humerus to observe the overlapping portion of the cadavers were minutely dissected. After resection of the acromion supraspinatus and infraspinatus. The supraspinatus muscle and its and removal of the coracohumeral ligament, the infraspinatus mus- origin were carefully investigated macroscopically. In 4 shoulders, cle was carefully investigated macroscopically. After the orientation muscle fibers were completely removed to examine the direction of muscle fibers was confirmed, the muscle was peeled from the and insertion of the supraspinatus tendon in detail. The supraspina- proximal part to the distal part and the insertion of the infraspinatus tus muscle fibers originated from the spine of the scapula and the tendon was examined. In 4 shoulders, muscle fibers were com- supraspinatus fossa, and they were running toward and attached pletely removed in water and the direction and insertion of the ten- to the thickest tendinous portion, which was located at the anterior don were examined. The infraspinatus muscle originated both part of the supraspinatus muscle. This tendinous portion was strongly from the inferior surface of the spine of the scapula and the infraspi- attached to the most anterior portion of the greater tuberosity adja- natus fossa, and inserted to the greater tuberosity. The muscle fibers cent to the bicipital groove or at the lesser tuberosity (21.3%). An- originated from the spine were running dorsally and horizontally to other part of the supraspinatus, which was located posteriorly, the greater tuberosity. On the other hand, the fibers from the fossa was attached to the greater tuberosity adjacent to the articular car- were running ventrally and diagonally to the greater tuberosity. tilage as a thin membrane. The insertion of the supraspinatus tendon These fibers were merged at the insertion. The infraspinatus tendon revealed to be the most anterior portion of the greater tuberosity and had vast insertion to the greater tuberosity, and the most anterior part e4 Abstracts J Shoulder Elbow Surg

of the tendon was inserted to the most anterior portion of the greater 027 Pullout Strength of Suture Anchors for the Rotator Cuff tuberosity, bordering on the most anterior part of the supraspinatus Repair: A Biomechanical Study tendon. The supraspinatus tendon is regarded as the most affected Obata Masanori, Department of Orthopaedic Surgery, Nishioka tendon in rotator cuff tears. However, the results of this study sug- Daiichi Hospital gested that the infraspinatus tendon could be involved in the majority Aoki Mitsuhiro, Department of Physical Therapy, Sapporo Medical, of rotator cuff tears. The infraspinatus may act not only in external University School of Health Sciences rotation but also in abduction, because the infraspinatus tendon To compare the pullout strength of different types of suture anchors was inserted to the most anterior part of the greater tuberosity. for a rotator cuff repair. 4 types of metallic suture anchors (FASTIN RC anchorÔ, Mitek; CorkscrewÔ, Arthrex; Super Revo anchorÔ,Linva- tec; TwinFixÔ, Smith & Nephew) (6 per group) were inserted into 3 different densities of urethane-made blocks (10, 15, 20 lb/ft3). The 025 The Insertion of the Pectoralis Minor Tendon : An original sutures in each anchor were replaced by 2 threads of stronger Anatomic Study in Cadavers type sutures (Fiber wire, Arthrex). Anchors were inserted perpendicu- Yoshimura Hideya, Sugaya Hiroyuki, Mochizuki Tomoyuki, Maeda lar to the block surface and then pulled reversely. Both failure load and Kazuhiko, Matsuki Keisuke, Nakagawa Teruhiko, Muneta Takeshi, failure mode were recorded. Data were analyzed using a Bonferroni/ Akita Keiichi, Department of Orthopaedic Surgery, Tokyo Medical Dunn multiple comparison procedure. In the urethane blocks of 10 and Dental University, Funabashi Orthopaedic Sports Medicine and 15 lb/ft3, the average failure load was 127N and 265N for FAS- Center, Unit of Clinical Anatomy, Graduate School, Tokyo Medical TIN, 151N and 297N for Corkscrew, 154N and 312N for Super and Dental University, Department of Orthopaedic Surgery, Chosei Revo, 153N and 348N for TwinFix respectively,all of which failed be- Public Hospital, Department of Orthopaedic Surgery, Douai Memo- tween the anchor and the block. In the urethane blocks of 20 lb/ft3,the rial Hospital sutures failed at approximately 500N of failure load in all anchors, Previous studies reported a presumably unusual bony attachment and therefore anchor pull-out tests were interrupted. In the 10 lb/ft3 of the pectoralis minor muscle. However, less attention has been block, there were no significant differences in failure load among 4 given to the insertion of the continuation to the glenohumeral joint. types of anchors. In the 15 lb/ft3 block, FASTIN had a statistically sig- The purpose of this study was to evaluate the frequency of this abnor- nificant lower failure loadthan the other anchors (p < 0.01), and Twin- mal insertion of the pectoralis minor muscle, and also to investigate Fix had a statistically significant greater failure load than the other (p < the relation between this continuation and the capsule. 0.01). There were no significant differences in failure load among any 81 anatomic specimen shoulders from 41 cadavers were dis- type of anchor in a low-minute urethane block, while in a middle- sected. The insertion of the pectoralis minor tendon to the glenohum- minute urethane block TwinFix had a significant greater failure load. eral joint was carefully investigated. The pectoralis minor tendon ran beyond the coracoid process and extended to the superior portion of the glenohumeral joint in 28 out of 81 specimens (34.6%). The continuing insertion divided the coracoacrominal ligaments 028 Biomechanical Comparison of Suture Anchor Pullout into two limbs. The continuation was more variable, and consisted Strength with Different Numbers of Sutures of the whole tendon in 6, the middle part in 5, the lateral part in 15, Horaguchi Takashi, Kato Yuki, Ryu Junnosuke, Department of Ortho- and the medial part in 2 specimens. Furthermore, the pectoralis mi- paedic Surgery, Nihon University School of Medicine nor tendon inserted to the posterosuperior border of the glenoid in Kato Atuo, Motojima Sayaka, Negishi Shinichi, Okano Tatumasa, 6, to the greater tuberosity in 7, and both to the glenoid and the Saito Akiyoshi, Department of Orthopaedic Surgery, Surugadai greater tuberosity in 15 specimens. The prevalence of the anoma- Hospital, Nihon University lous insertion of the pectoralis minor tendon revealed to be as The purpose of this study is to compare the pullout strength of a su- high as 34.6% in the present study. This may suggest that the pec- ture anchor with different numbers of sutures. We specifically re- toralis minor tendon plays an important role in the stability of the viewed the load at approximately 3mm of displacement at the glenohumeral joint. repair site to be a clinical fixation failure. Anchors were tested in the glenoid of the porcine scapulas. Anchors tested included the Panalok with single No2 Ethibond (PS Group), the Panalok with double No2 Ethibond (PD Group), Panalok Loop with single No2 Ethi- bond (PLS Group), Panalok Loop with double No2 Ethibond (PLD Group), GII with single No2 Ethibond (GS Group), and GII with dou- 026 Functional Anatomy of Serratus Anterior Muscle by ble No2 Ethibond (GD Group). An autograph AG-2000TB machine a Cadaver Study (Shimazu, Japan) applied tensile loads parallel to the axis of inser- Hamada Junichiro, Kuwano Kyoritsu Hospital tion to failure, and the mean strength to make 2 and 4mm gaps Akita Keiichi, Unit of Clinical Anatomy, Tokyo Medical and Dental was calculated. In the cases of forming 2mm gap formations, the University, Graduate School PLD group was significantly stronger compared to the PLS group To clarify the anatomy of the long thoracic nerve (LTN) and func- (p ¼ 0.008). There was also a significant difference between the tional anatomy of 3 parts of the serratus anterior muscle (SA) from GS group and the GSD group (p ¼ 0.008). In the 4mm gap forma- innervations and the shape of each fiber. We collected the 10 shoul- tions, the PS group was significantly stronger compared to the PD ders of 5 cadavers (3 males and 2 females, average age 82,4 years group (p ¼ 0.029). There was a significant difference between old). The upper, middle, and lower parts of SA were classified ac- the PLS group and the PLD group (p ¼ 0.032). It is possible that cording to the Eisler’s definition. We observed which components the repair tissues are displaced from the glenoid rim before the ulti- from C4, C5, C6, and C7 innervated each part of the SA. The upper mate pullout strength is reached. This study demonstrated that the part was mainly innervated by C5 fiber and also C4, C6, or C7 fi- load to create 2 and 4mm of displacement was increased by in- bers connected to the parts in 8 of 10 shoulders. The long thoracic creasing the number of sutures threaded through an anchor. nerve consisted of C6 and 7 fibers innervated middle and lower parts. The cross section area of the upper part was wider than those of other parts, and the upper part ran in the direction of the anterior compared to that of the middle part. The upper part of SA may be 030 Analysis of Three-Dimensional Motion of the Shoulder worked as the center of the scapula in an up and downward rota- Relationship between Elevation and Rotation tion. Degenerative change or sprain of cervical spine and direct Inui Hiroaki, Ninomiya Hiroki, Komai Masahiko, Hashimoto Taka- trauma to the medial scalenus muscle may have caused damage shi, Nobuhara Katsuya, Nobuhara Hospital and Institute of Bio- of LTN and then dysfunction of the SA. mechanics J Shoulder Elbow Surg Abstracts e5

External rotation is obligatory for the shoulder reaching the posi- 034 Effectiveness of Reconstruction using a Palmaris Longus tion of maximum elevation. To clarify the relation between elevation Graft for a Massive Rotator Cuff Tear with Iimpaired Shoulder and rotation is essential for understanding of shoulder movement Joint and a variety of pathologic states including instability and contrac- Hirooka Takahiko, Department of Orthopaedic Surgery, Onomichi ture. However, there have been few studies approaching this topic Municipal Hospital University in vivo. The present study investigated the relation between eleva- Hashizume Hiroyuki, Department of Orthopaedic Surgery, Kasaoka tion and rotation using a 3D motion capture system developed in Daiichi Hospital our hospital. The subjects included 15 men with healthy shoulder. Some elderly patients with a massive rotator cuff tear have severe The average age was 31 years old. The latest Qualisys ProReﬂex impairment of the shoulder joint elevation. When the rotator cuff is System including 7 infrared light CCD cameras analyzed the reﬂect- severely degenerated and fragile, tear is very likely to occur during ing markers attached on the bilateral epicondyles of the elbow, the rehabilitation after surgery by the McLaughlin’s method alone. In acromion, and several sites of the trunk and the spine of each sub- this study, we investigated the usefulness of Palmaris longus graft in ject. The arm was actively moved from the dependent position elderly patients with a massive rotator cuff tear accompanied by im- with neutral rotation to the maximum elevated position on 4 planes paired elevation of the shoulder joint. The subjects were 13 patients (0,30,60,90 anterior to the coronal plane). Rotational angles with 13 impaired shoulders incapable of active elevation of the shoul- along the axis during elevation were compared among 4 planes. der joint from the lowered position for 3 months or longer due to a ro- The amount of change in the angle of rotation depended on the tator cuff tear, and diagnosed with massive rotator cuff tear by MRI path along which the arm was elevated. It averaged about 40on before surgery. The age at the time of surgery was 62-81 years the scapular plane (30anterior to the coronal plane). Those values old. 12 patients had no clear cause of injury. 2 patients had rheuma- got smaller when the arm was elevated more anteriorly. Tilting of the toid arthritis, and 1 patient had Parkinson’s Disease. Rotator cuff re- humeral shaft generated rotational motion on the glenoid during el- pair and Palmaris longus graft were performed on these patients. The evation. These angles were different among the 4 planes even if the postoperative acquisition of shoulder joint function was investigated. angles of the humeral rotation in the starting position with the arm at The average point of the post-operative JOA score was 85.7 points. the side and in the end position with the maximum elevation were the 9 patients became capable of active elevation of the shoulder joint same among 4 planes. That would cause differences in the amount for more than 150 after surgery. 2 patients with a poor outcome of rotational angles along the humeral axis. had rheumatoid arthritis and Parkinson’s Disease. Palmaris longus graft may be effective for a massive rotator cuff tear in elderly patients with advanced impairment of the shoulder joint, but caution of complications such as rheumatoid arthritis is necessary, and application of the procedure should be carefully selected.

033 Shoulder Muscle Power and Post Operative Results of Fascia Lata Patch Grafting for a Massive Rotator Cuff Tear 037 Standardization of Rotator Cuff Reconstruction Takei Isao, Mura Nariyuki, Momonoi Yoshiyuki, Tsuruta Daisaku, Procedure for Massive Tears Ogino Toshihiko, Department of Orthopaedic Surgery, Yamagata Imada Koichi, Aoki Masato, Department of Joint Surgery and Sports University School of Medicine Medicine, Kurobe City Hospital Goto Yasuo, Department of Orthopaedic Surgery, Sagae Municipal The purpose of this study was to clarify the merit of our operation Hospital method for a massive rotator cuff tear. If suturing by McLaughlin’s Matsuda Masahiko, Department of Orthopaedic Surgery, Saiseikai method after abrasion and traction of torn cuff provided insufficient Yamagata Saisei Hospital covering of the humeral head, we chose fascial patch procedure us- Fascia lata patch grafting is one of the possible methods for re- ing our standardized technique. In our protocols of patch proce- pair of a massive rotator cuff tear for which we are unable to perform dure, the important points were sewed graft to the torn cuff edge a primary suture. However, some researchers have indicated that firmly by the double mattress suture technique, anchored the tendon shoulder muscle power recovery of such cases is not always ade- to the anatomical foot print of the major tuberosity, and removed an quate. So we evaluated muscle power and postoperative results of adequate thick graft with a single layer from the fascia. the fascia lata patch grafting method for massive rotator cuff tear, 28 operated patients with a massive rotator cuff tear were eval- as there is few precise reports elucidating muscle power recovery, uated one year after operation. McLaughlin’s method was per- though. The cases were 12 patients (9 males and 3 females) with formed on 10 patients and fascial patch procedure was done in a primary massive rotator cuff tear who underwent fascia lata patch 18 patients. Repair integrity was estimated by Sugaya’s classifica- grafting. The age on average was 60.9 years old at the time of sur- tion through MRI. The rate of healed case (Type I, II, III) was 90% gery. They were followed up for over 2 years postoperatively (34 in McLaughlin’s method, and 92.9% in the patch procedure. The months on average), and could be examined directly in our offices mean JOA score improved from 62.1 to 90.6 in McLaughlin’s at the last time we saw them. The results were evaluated using the method, and from 56.9 to 90.3 in the patch procedure. All the cases Japanese Japan Orthopaedic Association (JOA) score and it signif- returned to their jobs. A rate of successful anatomical healing rate icantly improved from 67.0 to 89.5. Isometric muscle power was must be respected as an index to judge whether operation methods measured with MicroFET. Shoulder abduction strength significantly are proper. Both of the rate and clinical outcome of our methods improved from 18.5 to 75.8 N at 45 degrees of abduction, from were satisfactory. 14.2 to 55.4 N at 90 degrees of abduction. External rotation strength significantly improved from 19.9 to 53.7 N. Internal rotation strength improved from 77.2 to 122.4 N, but it was not significant. The external rotation strength did not recover well compared 038 A Second-look Arthroscopy Evaluation Of Post Rotator with that of abduction. This may be because a massive rotator cuff Cuff Reconstruction With Fascia Lata Grafting: A Case Report tear often includes infraspinatus muscle atrophy and fatty degenera- Matsumoto Isshin, Ito Yoichi, Tomo Hiroyasu, Nakao Yoshihiro, tion, so that it is fundamentally difficult to recover external rotation Nakano Motohiro, Nakamura Nobuyuki, Manaka Tomoya, Naka strength. We concluded that fascia lata patch grafting is an effective Yoshifumi, Takaoka Kunio, Department of Orthopaedic Surgery, method for repair of massive rotator cuff tear and both abduction Osaka City University Graduate School of Medicine and external rotation strength can significantly recover, but we We described the case of a massive rotator cuff tear treated by should do something more to improve the extent of the external rota- a reconstruction with fascia lata grafting and evaluated by a section strength recovery. ond-look arthroscopy. Case: A 56-year-old man who had been e6 Abstracts J Shoulder Elbow Surg

a manual laborer and lifted heavy objects for 30 years was referred trant shoulder pain after trauma, attention should be paid to the pres- to our clinic. He presented himself with a history of discomfort in the ence of a partial rotator cuff tear, including a horizontal tear. right shoulder associated with progressive pain and with a loss of motion. A physical examination confirmed that active motion was restricted to 90 degrees flexion and 60 degrees abduction. A Hawkin- s’impingement was present; a supraspinatus (SSP) test indicated 040 Rotator Cuff Repairs in the Weight Bearing Shoulder weakness of the SSP.An MRI scan showed massive rotator cuff tears. Kasashima Toshihiko, Department of Orthopaedic Surgery, Bibai Clinical results were evaluated using a Japanese Orthopaedic Asso- Rousai Hospital ciation shoulder scoring system (JOA score) and the preoperative Suenaga Naoki, Department of Orthopaedic Surgery, Hokkaido score was 41 points. Surgical treatment was performed with arthro- University scopic debridement for a partially torn long head of the biceps bra- Although it has been reported that a large percentage of persons chii, inflammatory synovial tissue and degenerative rotator cuff torn with paraplegia suffer from a tear of the rotator cuff, there are few re- end with subacromial decompression. Arthroscopic evaluation reports addressing the surgical treatment, and no report on the evalua- vealed massive rotator cuff tears measured 40mm in width and tion of repaired tendon using MR imaging. The purpose of this study 50mm in length; rotator cuff defect measured 20mm in width and was to evaluate the clinical results and MRI findings of repaired tendon 15mm in length and remained after sufficient debridement of the sur- in the weight bearing shoulder. 7 male patients (8 shoulders) with ro- rounding tissue around the torn tendon. Rotator cuff reconstruction tator cuff tears underwent rotator cuff repair. Their ages averaged 53 with double folded fascia lata grafting for the defect was performed years old and ranged from 45 to 62 years old. There were 5 middle, 1 with 2 suture anchors. The JOA score had improved 81 and 87 large and 2 massive tears. Tendon-to-bone repair was accomplished points at 3 and 6 months follow up respectively. Active motion in 7 shoulders. Synovectomy, capsular shift and rotator cuff repair was recovered to 170 degrees flexion and 160 degrees abduction. was done in one shoulder with a massive tear and severe synovitis. A second-look arthroscopy evaluation revealed good continuity and Postoperatively manual wheelchair use was prohibited until 8-12 integration between rotator cuff tendons and grafted fascia lata as weeks after the procedure, and transfers were until 10-14 weeks. well as fascia lata and the greater tuberosity with almost normal The follow-up period averaged 36 months (range, 8-74 months). shoulder articulation. Our current second look evaluation indicated The patients were evaluated with JOA score and MRI findings of the that fasia lata grafting might be one of the useful options for the re- repaired tendon. The preoperative JOA score averaged 53 points, construction of massive rotator cuff tears. ranging from 21 to 68. The postoperative JOA score improved 94 points (range, 87-100). The postoperative range-of-motion and strength improved in all shoulders. All patients could transfer indepen- dently. There were no MRI findings of re-rupture in all shoulders except 1 shoulder with a massive tear. This study showed that surgical repairs in a weight bearing shoulder were effective methods that provided improvement of shoulder function at intermediate follow-up evaluation.

039 Clinical Features of Rotator Cuff Tears Occurred in the Population Younger than 40 Years Old Nakagawa Shigeto, Mizuno Naoko, Department of Orthopaedic Sports Medicine, Yukioka Hospital Yoneda Minoru, Yamada Shinichi, Department of Sports Medicine, 045 Clinical Results and Preoperative X-ray Findings of Osaka Kosei-nenkin Hospital Rotator Cuff Tears Treated Operatively Using Therapeutic Hayashida Kenji, Department of Orthopaedic Surgery, Hoshigaoka Exercises from an Early Stage after Surgery Kosei-nenkin Hospital Takahashi Akira, Hori Takeo, Matsumoto Risa, Kadowaki Ayahiro, The purpose of this study was to clarify the clinical feature of ro- Saito Tomoyuki, Department of Orthopaedic Surgery, Yokohama tator cuff tears occurred in a relatively younger population. Among City University patients who underwent arthroscopic rotator cuff repair, 19 patients Clinical results of rotator cuff repairs using the same therapeutic ex- younger than 40 years old were investigated. Regarding their in- ercises from an early stage after surgery were investigated and com- jured mechanism, 6 shoulders in the overuse group were injured pared with the preoperative X-ray findings. 70 shoulders with rotator through repetitive overhead activity, and 13 shoulders in the trauma cuff tears treated operatively and followed by active-assistive exercises group were injured during a sports activity or a traffic accident, in- in a supine position from 1 week and active exercises standing from 3 cluding 10 shoulders injured by a fall. Several clinical features weeks after surgery were evaluated. The average age was 63 years were retrospectively investigated. As a result, there was an articu- old and follow-up periods were 11.9 months. The operative proce- lar-side partial tear in 10, a bursal-side partial tear in 3, and an intra- dures were McLaughlin’s method in 41 shoulders, side to side sutures tendinous horizontal tear in 6, and their mean age was 30.4, 37, in 9, acromioplasty in 17 and a tendon transfer in 3. The preoperative and 27.3 years old, respectively. While the overuse group showed X-ray findings were classified into 5 groups : group A, superiorly mi- 4 articular-sides, 1 bursal-side and 1 intratendinous tear, in the grated humeral head and narrowed joint space in 4 shoulders; group trauma group there were 6, 2 and 5, respectively. Shoulder pain B, only superior migration in 7; group C, only narrowed joint space in was recognized in all shoulders, and disturbed their daily activity 3; group D, no changes in 36; group E, subacromial spurs more than 5 in 15. Moreover, difficulty in elevation was complained of by 8 mm without superior migration in 20. The postoperative results were shoulders in the trauma group, and among them disability of active assessed according to the JOA score and the failure rate of each group abduction was recognized in 4. Regarding their location of tears, in was investigated. No significant differences in the preoperative JOA the trauma group most tears were recognized at the anterior aspect score were found in the 5 groups. The postoperative JOA scores of the supraspinatus tendon, and 4 of 6 horizontal tears were recog- were 62.9 6 3.6 in group A, 75.1 6 12.6 in B, 78.0 6 12.2 in C, nized at the central aspect of the supraspinatus tendon. Posterior 90.4 6 7.5 in D, and 83.6 6 11.1 in E. Especially groups D and E capsular tightness and presence of the greater tuberosity notch on treated by McLaughlin’s methods showed a significant higher score the humeral head were not so frequent in the trauma group. While at follow-up. Rotator cuff repairs with the same therapeutic exercises inflammation in the subacromial bursa was rarely seen in either from an early stage after surgery for groups A, B and C showed group, granulation tissue was recognized after the exposure of the poor results. Groups A and B with a superior migration of the humeral tear site in 2 in the overuse group and in 3 in the trauma group head showed a high failure rate of 40% compared with 4.7% in group and it was especially frequently seen in horizontal tears (3 of 6 C, D and E with no superior migration. For these cases more careful tears). In conclusion, in relatively younger patients showing recalci- postoperative exercises were recommended. J Shoulder Elbow Surg Abstracts e7

046 Early Rehabilitation Program after Rotator Cuff Repair with partment of Orthopaedic Surgery, Gunma University, Graduate a Shoulder Mobilizer and an Active Exercise in a Flexed Position School of Medicine Oizumi Naomi, Suenaga Naoki, Hisada Yukiyoshi, Minami Akio, (4) A rotator cuff tear is classified into a full thickness tear and Department of Orthopaedic Surgery, Hokkaido University School a partial thickness tear. Various visual analog scales (VAS) of the of Medicine shoulder joint in cases of rotator cuff tear were evaluated preopera- Early passive exercises after an operation for a rotator cuff tear tively. These scales included evaluations at night, at the time of exer- often creates difficulty due to pain and increased muscle tonus. cise and at the time of rest. The purpose of this study was to examine We developed a new rehabilitation protocol using an original shoul- the characteristics of each VAS evaluation into 3 types of rotator cuff der mobilizer and an active exercise in the supine flexed position. tears. Since January 1999, 123 patients of rotator cuff tears were The objective of this study was to compare the ROM and pain of operated on in our institute, and 86 of them were evaluated preop- the shoulder between the former and our new protocol. Fifty-two eratively about their VAS. Their mean age was 61.8 years and the shoulders were classified as group I (GI); no tendon-to-bone repair, mean affected period was 20.2 months. There were 52 males, or group II (GII); with a tendon-to-bone repair. In the former protocol, and 34 females. Each case was classified into the articular side passive exercises started the next day after the surgery (GI) or in 1 tear group (group A), the bursal side tear group (group B) and the week (GII). In our new protocol, the active exercises and the mobi- complete tear group (group C). The VAS evaluations of each group lizer started the next day; no passive exercises were applied. There were statistically evaluated (The Tukey-Kramer method). There was were 10 former-GI, 9 new-GI, former-GII, and 14 new-GII. The post- not significant difference between the age and affection period of operative passive flexion (Flex), the external-rotation (ER), and the in- each group and there was significant difference about various ternal-rotation (IR), and the amount of pain relief suppository used VAS evaluations. postoperatively were evaluated. The ROM (deg.) was Flex (1w/ 2w/4w); 109/139/133, ER; 34/53/44, IR 44/53/54 in the former-GI, Flex; 130/144/154, ER 51/71/70, IR; 49/59/54 in the new-GI, Flex; 117/134/145, ER 43/60/65, IR; 36/35/46 in the 049 Arthroscopic versus Mini-open Rotator Cuff Repair: former-GII, Flex; 117/139/153, ER 37/53/63, IR; 44/52/53 in Analysis by Postoperative Pain and Inflammation the new-GII. All motions but the ER in GII improved in the new pro- Tagaya Kenichi, Department of Orthopaedic Surgery, Sakaide St. tocol. The amount of suppositories used in day 1 and 2 significantly Martin Hospital increased more in the new-GII than the former-GII; it is probably be- Comparisons were made to identify the transition of pain-reliev- cause the exercises started earlier in the new protocol than the for- ing doses and their inflammatory reaction after an arthroscopic mer protocol. Favorable ROM was obtained in most motions (Method-A) or a mini-open rotator cuff repair (Method-M). We re- without any passive exercises by using the mobilizer and the active viewed the cases of mini-open-group (Method-M) including 8 males exercise. It is considered that the active exercises assisted in getting and 9 females of ages 51-71 average 62.4 and the arthroscopic- better concentric motion of the humeral head and the mobilizer pro- group (Method-A) including 16 males, and 22 females of ages vided muscle relaxation. To improve ER in GII, additional exercises 25-83, average 63.1. Method-M group underwent operations 10 should be considered. cases/right and 7 cases/left, using 2.2 suture anchors for 178 minutes average with a follow-up of 2.8 years. Their average JOA shoulder score improved from 59.5 (pre/operation) to 94.5 when reviewed. While, method-A underwent operations 28 cases/right 047 The Effect of Pubivacaine Infiltration Around the Wound and 10 cases/left, using 2.1 suture anchors, for 189 minutes with and Into the Joint for Post-operative Pain After Rotator Cuff a follow-up of 1.6 years. Their average JOA shoulder score im- Repair Surgery proved from 59 to 94.4. We investigated the dosing frequency of Watanabe Chisato, Kinoshita Mitsuo, Fukunishi Kunimoto, Mihata postoperative pain-relief on the operation date and the postopera- Teruhisa, Abe Muneaki, Department of Orthopaedic Surgery, tive 1/2/3/4/5 days. Diclofenac sodium suppository 25mg was Osaka Medical College dosed 0.7/0.7/0.3/0.1/0.1/0 times to the Group M, while Postoperative pain from cuff repair surgery is so severe that it 0.6/0.3/0.3/0.2/0.1/0 to the Group A. Significant difference may influence postoperative rehabilitation, and often lead to com- was identified only in the first postoperative day (p ¼ 0.005). Pen- plex regional pain syndrome. This study investigated the effect of lo- tazocine intramuscular injection 15mg was dosed 0.7/0.4/0.3/ cal anesthetic use before skin closure. 15 patients (average age 0/0/0 times to the Group M, while 0.4/0.1/0.1/0/0/0 to the 56.1 years old) undergoing rotator cuff repair surgery were studied. Group A with no significant differences except on the first (p ¼ They received local anesthetic (0.5% pubivacaine: 20-30cc) infil- 0.001) and second (p ¼ 0.002) postoperative days. Blood cell trated into the wound and joint before skin closure. In addition, count transited similarly for both. The preoperative and postopera- 15 patients (average age 54.1 years old) who did not receive a local tive (1st/4th/7th/14th/21st day) average CRP were respectively anesthetic were studied as the control. Pain intensity after surgery 0.1/3.1/4.9/1.1/0.3/0.1 mg/dl for the Group M, while 0.1/ was measured by the amount of NSAID (Diclofenac Na) and opioid 1.8/2.8/0.8/0.2/0.1 mg/dl for the Group A with no significant (Pentazocine) used within 48 hours after surgery. The degree of flex- differences except on the first (p ¼ 0.0005) and 4th (p ¼ 0.0007) ion at 3, 6 months after surgery and the clinical results using the JOA postoperative days. Method-A indicated less postoperative pain of score were evaluated. The amount of NSAID (110 6 67.3 mg) was the objectified scores, and less increase of CRP than method-M. significantly (p< 0.01) lower than that in the control group (176 6 70.0 mg). The amount of opioid (4.0 6 6.87 mg) was significantly (p< 0.01) lower than that in the control group (17.0 6 13.73 mg). There was no significant difference between the two groups in either the degree of flexion or the clinical result. Local anesthetic use into 050 The Evaluation of Bone Mineral Density and Bone the wound and joint before skin closure was an effective method Strength in the Proximal Humeral Head Cancellous Bone of of pain control and it did not influence the clinical result. Elderly People Yamada Mitsuko, Yamaji Tetsuo, Depart. Orthopaedic Surgery Fujita Health University second hospital (Aim)Since bone mineral density (BMD) and bone strength of the 048 Various Preoperative VAS Evaluations by a Rotator Cuff proximal humeral head affect the stability of the internal fixation ma- Tear terial at the operative treatment, we tried to evaluate the relationship Kobayashi Tsutomu, Takagishi Kenji, Osawa Toshihisa, Suzuki between BMD and bone strength in the proximal humeral head can- Hideki, Yamamoto Atsushi, Shitara Hitoshi, Shinozaki Tetsuya, De- cellous bone using cadaver humerus. e8 Abstracts J Shoulder Elbow Surg

(Method) The BMD of 6 cadavers humerus (2 males and 4 fe- No comment in particular about his past history, but he had prac- male, mean age 83.2). BMD was analyzed by XP-26 (Norland ticed kendo for 4 years. After diagnosis by other orthopaedists, he Co.). BMD, distinguished by several colors, was measured at 3 re- was referred to our hospital. He did not feel an ROM limitation. gions of interest (region A: top of humeral head at the acromion When he elevated his left arm to 135 degrees, suddenly the sterno- side, region B: the area of subchondral bone at the glenoid side, re- clavicular joint was subluxated forward without pain. As he put gion C: the middle of the humeral head). On the coronal plane the down his arm to 45 degrees, the subluxation was easily reposi- osteotomy was performed on the middle of humeral head and sliced tioned. X-rays did not reveal any abnormal lesions around the left 1 cm thickness. The maximum load value at three regions were mea- shoulder, and bilateral clavicle lengths were equal. MR images sured by the compression test of the humeral head slice using a uni- did not demonstrate any articular disc lesion. We performed conser- versal material examination machine (Instron 4505) with the vative treatment on him because of the lack of pain. We forbade him compression bar (8.5 mm diameter) at the speed 0.04 mm/sec. to do kendo because subluxation was occurred frequently when he (Results) Mean BMD (g/cm2) of the region A was 0.469, B did kendo. Overuse in a sport’s activity and minor trauma have been 0.712 and C 0.466. Region B was significant difference from A reported to cause spontaneous sternoclavicular joint subluxation. and C (p ¼ 0.05). The mean maximum load value (N) was 134 at Operative treatment for this morbidity is controversial because spon- region A, 211 at B and 84 at C. There were significant difference taneous recovery may be expected in many cases. In this case, he A Vs B and B Vs C (p ¼ 0.05). There was positive correlation be- did not suffer any trauma to his chest, so we treated it as a spontane- tween BMD and the bone strength at the region A and B. ous sternoclavicular joint subluxation. We should note that a over- (Discussion) Our result shows that the BMD measurement is the head sport should be restricted because it might inhibit the healing useful method to judge the stability when elderly patients with prox- of this morbidity. imal humeral head fracture are treated by screw fixation. Key words: Fspontaneous subluxation of the sternoclavicular joint, overhead sports, conservative treatment.

052 AO Type C: 2-, 3-Part Fractures of the Proximal Humeral Sakamoto Yoshihiro, Mondori Takamitsu, Department of Orthopae- 054 Clinical Evaluations of Distal End Fractures of the Clavicle dic Surgery, Jonai Hospital Namura Takehiko, Department of Orthopaedic Surgery, Matsushita Nakagawa Yoshiyuki, Okumoto Hiroki, Department of Orthopaedic Memorial Hospital, Department of Orthopaedics, Graduate School Surgery, Uda City Hospital of Medical Science, Kyoto Prefectural University of Medicine Sakurai Goro, Department of Orthopaedic Surgery, Nishinara Morihara Toru, Takubo Yoshinori, Iwata Yoshio, Nakagawa Haru- Tyuou Hospital hiko, Kubo Toshikazu, Department of Orthopaedics, Graduate Hashiuchi Tomonao, Department of Orthopaedic Surgery, Kokuho School of Medical Science, Kyoto Prefectural University of Medicine Tyuou Hospital Kurokawa Masao, Department of Orthopaedic Surgery, Saiseikai The purpose of this study was to produce the clinical results of AO Suita Hospital type C 2-,3-part fractures. 36 cases without a dislocation were clas- The aim of the study was to evaluate the clinical results of distal- sified into 3 types; 2-part fractures of the anatomical neck (C1-3), 3- end fractures of the clavicle. We evaluated 72 distal-end fractures of part fractures of the valgus type (C1-1, C2-1), 3-part fractures of the the clavicle. There were 48 men and 24 women, the mean age was varus type (C1-2, C2-2). 2 cases classified in the 2-part fracture of 45.1 years old (range, 12-90 years old) and the mean follow-up pe- the anatomical neck were 94 year-old-women. 1 was treated by riod was 7.9 months (range, 6-13 months). The types of fracture prosthetic replacement, the other was treated conservatively, and were classified by Takubo’s classification. The clinical results were healed without avascular necrosis (AVN). 25 cases were classified evaluated by the range of elevation and duration of bone union in the 3-part of valgus type. They were 23 women and 2 men with on X-rays. TypeI fractures were 30 cases, 20 cases were treated an average age of 68 years old (ranging from 47 to 85). 21 cases non-operatively. In the non-operative group, a complete union was were treated surgically, and 4 cases were treated conservatively. All obtained in 17 cases and the average duration of bone union was cases healed without AVN, but 1 case fell into osteoarthritis. 9 cases 3.6 months. The other 3 cases were nonunion, and these patients were classified in the 3-part of varus type. They were one man and 8 were significantly older than the patients in the union group, but women with an average age of 72 years old (ranging from 62 to were free from pain or restriction of the ROM. TypeIIb fractures 80). All cases were treated surgically and healed without AVN. were 26 cases, in 18 cases treated with a tension band wiring, We had one rare case of valgus type, which included both an ana- a complete union was obtained in 16 cases. The other 2 cases tomical and a surgical neck fracture. It was treated surgically and were cutout, and these patients were significantly older than patients healed without AVN. We evaluated the results of AO type C 2-, 3- in the union group. Type V fractures were 8 cases treated with ten- part fractures and all cases had no AVN. But this study had a prob- sion band wiring or plate fixation. A complete union was obtained lem. It was difficult to classify these fractures only by X-P. It is possible in all cases. Type VI was 5 cases treated with a tension band wiring, that our materials included type B fractures. We suggest that 3D-CT all cases obtained a complete union. was very useful to classify these fractures.

055 Perforation of the Trachea by a Kirschner Wire after 053 A Case Report of Spontaneous Sternoclavicular Joint Surgery for a Clavicular Fracture. A Report of a Case. Subluxation Inoue Jun-ichi, Sakai Hiroya, Department of Orthopaedic Surgery, Ogino Shuhei, Murata Ryo, Matsuura Ryu, Sugioka Kaori, Depart- Saitama Medical Center, Saitama Medical University ment of Orthopaedic Surgery, Graduate School of Medicine, Chiba Aizawa Tomofumi, Department of Orthopaedic Surgery, Ayase Kou- University sei Hospital Matsuki Keisuke, Department of Orthopaedic Surgery, Chosei Hos- Shimada Noriaki, Department of Orthopaedic Surgery, Sashiougi pital Hospital Ochiai Nobuyasu, Department of Orthopaedic Surgery, University A 70-year-old man with a past history of pneumoconiosis under- of California, San Diego went a surgery for the fracture of the distal end of the right clavicle Spontaneous sternoclavicular joint subluxation is a rare disorder. with Kirschner wires and soft wire at a local hospital. He had sus- The aim of this study was to report on a case of spontaneous sterno- tained slight chest pain since 6 months after surgery and visited an- clavicular joint subluxation. A 10-year-old man noticed a protrusion other hospital because his chest pain was aggravated about 2 on his left chest and felt a click at the same time without any trauma. months later. Radiographs and CTs showed the migration of the J Shoulder Elbow Surg Abstracts e9

Kirschner wire, sticking into the trachea. He visited our hospital and (the acromiolcavicular joint, the acromion, the distal clavicle) and the tip of the Kirschner wire was observed by a bronchoscopy. The the coracoid process were operated on in 29 cases. Only the cora- migrated Kirschner wire was directly identiﬁed and removed coid process was operated on in 6 cases. Only associated injury through a right thoracotomy. The remaining Kirschner wires and was operated on in 4 cases. Dewar’s method was performed in soft wire were also removed from the clavicle. His postoperative 10 cases. Most of all healed satisfactorily, but 6 cases treated con- course was uneventful. Perforation of the trachea by a migrated servatively had a nonunion of the coracoid process and complained Kirschner wire is very unusual. In this case, pneumothorax did not of discomfort. The fractures of the coracoid process were oftenasso- occur when the migrated Kirschner wire perforated the pleura prob- ciated with complex injuries of the shoulder girdle. Especially, when ably because of the pleural adhesion due to pneumoconiosis, caus- the acromioclavicular joint mechanism were injured, we were care- ing only slight chest pain. The aggravation of chest pain was ful of its diagnosis, because fractures of the coracoid process were probably attributable to the perforation of the trachea by the further often overlooked. In unstable fractures associated with complex in- migrated Kirschner wire. When a Kirschner wire is used for fracture juries of the shoulder girdle, better results were achieved with surgi- surgery, it should be inserted certainly into bone and its end should cal treatment. be bent sufﬁciently to prevent it from migrating.

058 Therapeutic Results of a Coracoid Process Fracture with 056 Clinical Results of Percutaneous Cannulated Cancellous an Acromioclavicular Dislocation Screw Fixation for a Coracoid Process Fracture Shinmura Koutaro, Takase Katsumi, Yamamoto Kengo, Department Sugihara Takayuki, Department of Orthopaedic Surgery, Mishima of Orthopaedic Surgery, Tokyo Medical University Social Insurance Hospital A coracoid process fracture with an acromioclavicular joint (AC- Nakagawa Teruhiko, Department of Orthopaedic Surgery, Doai j) dislocation is a comparatively rare injury. The purpose of this study Memorial Hospital was to evaluate the therapeutic results for this injury. We treated 12 Ozawa Hidehiko, Tajima Yoshitaka, Nimura Akimoto, Ishizuki Ma- patients (all male) with a mean age of 45 (24 to 82). Two patients safumi, Muneta Takeshi, Shinomiya Kenichi, Department of Ortho- were treated conservative. On the other patients, the surgery was paedic Surgery, Tokyo Medical and Dental University performed with screws for a coracoid process fracture; additionally Hiratsuka Kentaro, Department of Orthopaedic Surgery, Kobari we used K-wire (6 cases) or Wolter-Clavicular plate (4 cases) for an Hospital AC-j fixation. We evaluated the therapeutic results more than 6 The clinical results of percutaneous cannulated cancellous screw months post injury using the Japan Shoulder Society AC-j score. In fixation for a coracoid process fracture were investigated. The per- all cases who underwent the surgery, a bone union was accom- cutaneous cannulated cancellous screw fixations for coracoid pro- plished without infection and breakage of the hardware. Postopera- cess fracture were performed on 6 shoulders from 1997 to 2006 tive subluxation of the AC-j was recognized in 3 patients. One of in our hospitals. There were 4 males and 2 females with an average them needed the resection of the distal end of the clavicle for severe age of 45.2 years old. There were 2 right sides and 4 left. 1 case pain caused by osteoarthritis of the AC-j. Excluding this case, there was an isolated coracoid fracture, 4 cases had an acromioclavicu- was no patient who recognized the AC-j pain or subcoracoid im- lar joint dislocation and 1case had a distal clavicle fracture. With pingement. The AC-j score was a mean 93 points (81 to 100 points). the anteroposterior view, the scapulolateral view and the axillary lat- On the other hand, pain remained in 2 patients treated conserva- eral view by image intensifier, the direction of the screw was deter- tively, and one of them got a no-union. The AC-j scores were 50 mined. A bone union occurred in all cases, and the alignment of the and 52 points. In the surgical treatment for a coracoid process frac- acromioclavicular joint dislocations were good. The postoperative ture with an AC-j dislocation, it was possible to obtain satisfactory ranges of motion of their shoulders were mostly good. During the op- therapeutic results. However, the patients treated conservatively ob- eration, the axillary lateral view by the image intensifier was useful tained poor results. to determine the direction of the screw. The clinical results of percutaneous cannulated cancellous screw fixation for a coracoid process fracture were good. 060 Clinical Features of Patients with Difficulty of Shoulder Elevation Caused by Cervical Spondylotic Amyotrophy Okuyama Noriko, Ogawa Kiyohisa, Nakamichi Noriaki, Ikegami 057 Fractures of the Coracoid Process of the Scapula - Hiroyasu, Department of Orthopaedic Surgery, Keio University Complex Injury of the Shoulder Girdle School of Medicine Nakagawa Yoshiyuki, Okumoto Hiroki, Department of Orthopaedic Inokuchi Wataru, Department of Orthopaedic Surgery, Tokyo Met- Surgery, Uda city hospital ropolitan Health and Medical Treatment Corporation, Ohkubo Hos- Sakamoto Yoshihiro, Department of Orthopaedic Surgery, Jyonai pital hospital Difficulty of shoulder elevation is mainly caused by shoulder dis- Fractures of the coracoid process of the scapula apparently are order. However patients with deltoid paresis by cervical spondylotic rare. The purpose of this study was to investigate the pathogenesis, amyotrophy (CSA) are sometimes referred to a shoulder surgeon. treatment and results of fractures of the coracoid process of the scap- We reported on the clinical courses of 19 patients with CSA to ana- ula associated with a complex injury of the shoulder girdle. The frac- lyze their clinical features in order to clarify the point of differentia- tures were classified into 3 groups according to the fracture site; tion from shoulder joint disorder. Of 8118 patients who consulted base type (57 cases, including 4 epiphyseal separations): base of the shoulder service of our department, 162 patients (2%) were di- the coracoid process was fractured, intermediated type (3 cases, in- agnosed as having cervical lesion. Nineteen patients were diag- cluding 1 epiphyseal separation): intermediate portion between nosed as having CSA based on the clinical features, especially, base and tip of the coracoid process was fractured, tip type: (7 deltoid palsy associated with weakness of the short rotators and bi- cases) tip of the coracoid process was fractured. The associated in- ceps, without definite sensory deficit. MRIs, plain X-rays, and electro- juries were as follows; dislocation of the acromioclavicular joint: 45 myographies were examined supplementarily. Their mean age was cases, fractures of the acromion: 13 cases, fracture of the distal clav- 60.3 years old, range 40-75, 15 males and 4 females. Symptoms at icle: 15 cases, fracture of the middle clavicle: 5 cases, dislocation of the onset, the duration, and the self-evaluation of their present status the shoulder: 3 cases. Only 3 cases which were a tip type, had no were investigated. At the onset, disability of shoulder elevation with- associated injuries. 18 cases were treated conservatively. 49 cases out pain appeared in 10 patients. Eight patients were aware of their were treated surgically. Both the acromioclavicular joint mechanism shoulder weakness with shoulder or neck pain. Nine patients e10 Abstracts J Shoulder Elbow Surg

obtained almost complete relief of symptoms within 3 months from the age of 3 or 4 and an osteotomy at a younger age could provide the onset. Muscle weakness or shoulder pain had still remained in a better result. 4 patients without ADL disability. Two showed no recovery from pain and weakness. Patients having CSA are sometimes wrongly diagnosed as having shoulder disorder, because it shows slight sensory deficit. Confirmation of biceps weakness is useful in the 070 Stability Ratio and the Glenoid Depth differentiation of CSA from shoulder disorders. Abe Hidekazu, Yamamoto Nobuyuki, Seki Nobutoshi, Kikuchi Kazuma, Minagawa Hiroshi, Division of Orthopaedic Surgery, Department of Neuro and Locomotor Science, Akita University School of Medicine 062 The Evaluation of Sensory Function for Patients with Itoi Eiji, Department of Orthopaedic Surgery, Tohoku University Suprascapular Nerve Palsy School of Medicine Ikegami Hiroyasu, Ogawa Kiyohisa, Nakamichi Noriaki, Matsu- The purpose of this study was to determine the stability ratio in mura Noboru, Shiono Shouhei, Department of Orthopaedic Sur- various directions of the glenoid and to correlate them with the gle- gery, School of Medicine, Keio University noid depth.9 fresh frozen cadaveric shoulders were used. All soft tis- Ajmani and Horiguchi reported on a cutaneous branch of the sues were removed and the glenoid was mounted horizontally on suprascapular nerve supplying the proximal-lateral one-third of the a 6-component load cell while the humerus was vertically clamped arm. There is, however, no paper that reports on the relationships to a device. A 50-N compressive load was applied. Measurement between the clinical symptoms and sensory disturbance in patients was performed in 40 different directions and repeated twice. The with suprascapular nerve palsy. We report on the usefulness of the glenoid depth was measured by a LASER sensor in 8 directions. evaluation of sensory function for suprascapular nerve palsy. We The forces resisting translation were recorded. Then the stability ra- treated 60 patients with suprascapular nerve palsy from 1985 to tio, defined as the peak translational force divided by the applied 2005. To study the usefulness of evaluating the sensory function, compressive force, was calculated. Pearson’s correlation coefficient we investigated the clinical progress and the results of the sensory was used to evaluate the relationships between the stability ratio and disturbance in 7 cases with suprascapuar nerve palsy in which the the glenoid depth. The stability ratio was greater in the superoinfe- sensory tests were done more than twice. As the sensory function, rior direction than in the anteroposterior direction. The greatest sta- we evaluated the vibration thresholds, pain, light touch, and the sen- bility ratio was detected in the inferior direction (52.9% at 180) sation of heat and cold. In all the cases, we found atrophy of the in- and the superior direction (48.3% at 10). On the other hand, the fraspinatus muscle, dullness around the shoulder joint, tenderness at smallest stability ratio was detected in the anterior direction the entrapment point. Three cases had ganglions treated by a punc- (27.1% at 90) and the posterior direction (26.2% at 280). The gle- ture. We diagnosed 4cases without a ganglion cyst as neuralgic noid concavity was deepest in the superoinferior direction and shal- amyotrophy from the characteristic clinical progress and electromy- lowest in the anteroposterior direction. A positive strong correlation ography. In the tests for evaluating the sensory function, there were was observed between the stability ratio and the glenoid depth (r ¼ no cases with abnormal vibration thresholds. There were 6 cases 0.92, p ¼ 0.001). The stability ratio was greatest in the superoinfe- with hypalgesia and hypothermesthesia in the region of the posterior direction and smallest in the anteroposterior direction. The gle- rior axilla and 5 cases with hypaesthesia in the same area. The eval- noid depth was strongly correlated with the stability ratio. uation of the sensory function for patients with suprascapular nerve palsy is useful to follow-up this palsy, because it is non-invasive, inex- pensive, and sensitive compared with MRIs and electromyogra- phies. 072 Pathology of Recurrent Anterior Glenohumeral Instability Associated with Capsular lesions Fujita Koji, Saisu Takashi, Department of Orthopaedic Surgery, JFE Kawatetu Chiba Hospital 064 Scapular Osteotomy for Sprengel’s Shoulder in Children Sugaya Hiroyuki, Moriishi Joji, Funabashi Orthopaedic Sports Med- before the Age of 5 icine Center Saisu Takashi, Kamegaya Makoto, Kenmoku Tomonori, Division of The purpose of this study was to analyze the relevant factors in Orthopaedic Surgery, Chiba Children’s Hospital recurrent anterior glenohumeral instability with an anteroinferior Fujita Koji, Takahashi Norimasa, Department of Orthopaedic Sur- capsular lesion. gery, JFE Kawatetu Chiba Hospital From 1998 to 2005, 294 shoulders with anterior glenohumeral Moriishi Joji, Funabashi Orthopaedic Hospital instability underwent arthroscopic stabilization in our institution. A Wilkinson’s scapular osteotomy for Sprengel’s shoulder has capsular tear was observed in 33 shoulders, which was 15%, and been historically performed on patients after the age of 5. We an HAGL lesion was observed in 11 shoulders, which was 4% have been trying this procedure in younger children because we be- among the 294 shoulders. The subjects consisted of 44 patients, lieve that early gain of scapula mobility is important to obtain more 22 males and 22 females, with an average age at the time of sur- normalized clinical results. The subjects were 9 shoulders in 8 pa- gery 32.3 years old. The findings of a preoperative 3-dimentionally tients with a mean age of 5.7 years old (range, 3.3-11.2 years reconstructed computed tomography were also assessed. All the pa- old) at the time of operation. The mean follow-up term was 5.5 tient underwent an-arthroscopic repair. years. The operation time, the amount of blood lost, the scapula We classified the capsular lesion through our arthroscopic inves- height on plain radiographs, the cosmetic grade (Cavendish) and tigation into 4 types: TypeI: the capsular tear was located only on the the range of motion before and after the operation were investi- glenoid-side, Type II: the capsular tear was spread from the glenoid- gated. The final results in the younger age group (Group A), in side to the humeral side, Type III: HAGL lesion, Type IV: the capsular which osteotomy was performed before the age of 5, was compared tear with an HAGL lesion. There were 19 Type I, 14 Type II, 8 Type with those in the older age group (Group B). There were no statistical III, and 3 Type IV shoulders. differences in operation time, the amount of blood loss, the cosmetic The majority of the type II capsular tears were located between grade (Cavendish) between the 2 groups. The mean maximum ac- the MGHL and the AIGHL, parallel to the superior border of the tive abduction at the final follow-up was higher in Group A than AIGHL. We believe that this separation between the MGHL and that in Group B, although there was no statistically significant differ- the AIGHL caused a functional deficit of the anterior capsular mech- ence. Improvement of the scapula height on plain radiographs after anism. Furthermore all types of capsular lesions could be an essen- the operation in Group A was significantly better than that in Group tial lesion causing a recurrent anterior dislocation. However, A B. We concluded that a scapular osteotomy could be safely done at Type I capsular lesion might sometimes be a secondary lesion. The J Shoulder Elbow Surg Abstracts e11

frequently associated bony Bankart lesion or subscapralis tears in performed on 7 out of 12 re-injured shoulders. Recurrence of Bank- older patients seemed to be more responsible for this instability. art’s lesion with a suture breakage was observed in every shoulder On the other hand, the Type II and Type III capsular lesion should during revision surgery. The factors related to a recurrence are sup- be an essential lesion causing recurrent anterior dislocation. Be- posed to be a large glenoid bony defect, multidirectional instability, cause the morphology of the glenoid rim were less affected. We insufficient anterior capsular shift, and poor healing of the anterior can expect an excellent outcome, through precise anatomical repair capsular mechanism on the anterior glenoid rim cartilage. To obtain of these capsular lesions along with a Bankart lesion. a better clinical outcome, careful selection of patients and refine- ment of repair technique raising initial fixation strength and healing potential are necessary. 074 Postoperative Evaluation of Healing in Bankart Lesions with MR Arthrography after Scopic Bankart Repair Using Suture Anchors 076 Shoulder rotational muscle power recovery after Suzuki Kazuhide, Tsutsui Hiroaki, Mihara Kenichi, Makiuchi Dai- Bankert & modified Bristow procedure suke, Nishinaka Naoya, Department of Orthopaedic Surgery, Amako Masatoshi,1,2 Imai Tomohito,2 Okamura Kenji,3 Tsuda Yosi- Showa University, Fujigaoka Rehabilitation Hospital fumi,1,2 Kaneko Masatoshi,1,2 Arino Hiroshi,1 Nemoto Koichi,1 The purpose of this study was to clarify the condition of reattach- 1. Department of Orthopedic Surgery, National Defense Medical ment of the labrum to the glenoid rim after an arthroscopic Bankart College, 2. Department of Orthopedic Surgery, Japan Self Defense procedure using suture anchors with an MR arthrography (MRA). Force Sapporo General Hospital, 3. Department of Orthopedic Sur- We studied 48 cases (35 males and 13 females) after surgery gery, Sapporo Medical University. with a recurrent anterior dislocation or subluxation. The patients We assessed the shoulder rotational muscle power recovery us- ranged in age from 16 to 53 years old (average, 24.7). An MRA ing the surgical / non-surgical ratio, and concluded that the muscle was performed at an average 11.8 months after the operation. In power recovery was retarded compared with our rehabilitation pro- the MRA with an axial image and an oblique axial image in abduc- gram. However, the retardation could be influenced by the contra- tion and external rotation (ABER) position, we evaluated the inva- lateral side. We reexamined the muscle power recovery only using sion of contrast materials between the labrum and glenoid rim the surgical-side data. Isokinetic concentric shoulder rotational mus- using the inferior 6 slice images of the glenoid rim. The 576 slices cle strength was evaluated in 40 patients treated with open Bankart were categorized into 1 of 3 groups : good, fair, and poor. We and modified Bristow procedure. We measured the peak torques in used the JSS Shoulder Instability Score (Instability Score) for clinical the surgical-side shoulders at 60, and 180 deg/sec angular veloci- evaluation. Axial images (total of slices : 288) revealed good ties at the pre- and post-operatively, and calculated the peak torque (83.3%), fair (14.9%), and poor (1.7%). Oblique axial images in to the pre-operative ratios (pre-op. ratio), and the peak torque to the the ABER position (total of slices : 288) revealed good (77.43%), body weight ratios (weight ratio). Positive coefficient correlations fair (19.8%), and poor (2.8%). The clinical results using the Instabil- were obtained between the pre-op and weight ratios and the postop- ity Score had no significant differences between the group that had erative period. Both ratios increased to the pre-operative level by 6 all good results in six slices and the group that had fair or poor results months post-operatively. The surgical-side muscle power was recov- more than 1 slice in 6 slices of axial images and oblique axial image ered strongly enough for the stability of the gleno-humeral joint by 6 in the ABER position. The healing of IGHL-LC to the medial glenoid months postoperatively. This recovery period was consistent with our neck was recognized in 97-98% of the total slices. A non-union or rehabilitation program. re-avulsion of the labrum to articular cartilage of the glenoid were recognized in 15 to 20% of the total slices, however the clinical results of arthroscopic Bankart repair were satisfactory. 078 Problems in Employing the Neer Classification Tamai Kazuya, Ohno Wataru, Takemura Michio, Kuroda Masahiro, Hamada Jun’ichiro, Department of Orthopaedics, Dokkyo Medical 075 Arthroscopic Bankart Repair Using Suture Anchor: University Minimum 2-Year Follow-up and Analysis of the Causes of We reviewed 397 proximal humeral fractures registered to the a Recurrence JSS database to clarify problems in employing the Neer classifica- Iwahori Yusuke, Kato Makoto, Sato Keiji, Department of Orthopae- tion. In addition to 1-, 2-, 3-, and 4-part fractures described by dic Surgery, Aichi Medical University School of Medicine Neer, we accepted valgus impacted fractures (Jakob) as a category Hanamura Hirokatsu, Department of Orthopaedic Surgery, Asahi of the fracture classification in the current study. It was found that dis- Hospital placement of fractured fragments in 1-part fractures, particularly in The purpose of this study was to evaluate the minimum 2-year fol- those with the fractured surgical neck, were often overestimated low-up result of arthroscopic Bankart repair, using suture anchors for by the surgeons as being 2- or 3-part fractures. It was also noted traumatic anterior glenohumeral instability. We retrospectively stud- that valgus impacted fractures had been diagnosed as 2-part, 3- ied 147 shoulders of 140 patients. There were 99 male and 41 fe- part, 4-part, or unclassifiable fractures by the surgeons, suggesting male patients. The average age at operation was 23.3 years old limitations of the original Neer classification for categorizing this (range, 14 to 43). 133 shoulders had recurrent dislocations or subtype of fracture. luxations, and 14 shoulders had initial dislocations. The mean interval from the time of the operation to the final follow-up evaluation was 35 months (range, 24 to 116). We performed an additional anterior capsular suture on 12 shoulders, superior labral repairs on 18 079 A Comparison between the Codman Classification and shoulders, a rotator interval closure on 22 shoulders, and a thermal the Neer Classification Based on the Data Base capsulorrhaphy on 20 shoulders at the time of their operations. Post- Ishige Noriyuki, Kuroda Shigehito, Maruta Kimiko, Mikasa Moto- operatively, the average loss of external rotation was 8.2 with the hiko, Matsudo Orthopaedic Hospital arm at the side, and 5.2 with the arm in 90 of abduction. The The purpose of this study was a comparison between the Cod- Rowe’s score ranged from 40 to 100 points (average 92.2), and man classification (CC) and the Neer classification (NC) based on 129 shoulders (87.8%) had a rating of good or excellent at the a data base (cases of multi-center). Simple X rays of 333 shoulders time of their final follow-up. Postoperatively, 12 shoulders experi- of the data base were investigated. In CC, we defined the type’s enced re-dislocation or re-subluxaion, and 13 shoulders demon- number clockwise from upward left and judged the fracture in the ex- strated a mild anterior apprehension sign. Revision surgeries were istence of the fracture line. We examined the relation between NC e12 Abstracts J Shoulder Elbow Surg

and C about the flexion angle. Types 2,8,13 and 16 of CC were not concept of assessing the circulation of the head and degrees of dis- included in the data base. There were 4 cases that were impossible placement and current knowledge of the humerus head circulation. to classify by CC, and 27 cases by NC. NC and CC were related So we conclude that Neer’s classification was practical. as follows: NC Type 1 (CC Types 4,6,7,9,10,11,12,14), 2-II(1.7), 2-IIIa(1,3,4,5,10,11), 2-IIIb(4,10,11), 2-IIIc(1,10,11), 2-IV(1,3,4,9,12), 2-VIa(4,9,12), 3-IV(1,4), 3-V(5), 3-VIa(4), 4(1), 4-VIa(1,12), unclassified (1,3,4,5,6,14,15, unclassified). In the 083 Classification of 4-part Fractures of the Proximal cases of conservative therapy of an NC 2-part fracture, the CC Humerus Type 4 had significantly more case’ over 120 degrees flexion than Nakagawa Yoshiyuki, Okumoto Hiroki, Department of Orthopaedic Type 11. In the cases of CC Type 4, the cases of less displacement Surgery, Uda City Hospital had a significantly better flexion angle. Therefore NC was better if Sakamoto Yoshihiro, Department of Orthopaedic Surgery, Jyonai it had more patterns of classification and CC was better if it had Hospital a concept of the displacement. Sakurai Goro, Department of Orthopaedic Surgery, Nishinaracyuo Hospital Hashiuchi Tomonao, Department of Orthopaedic Surgery, Kokuho- cyuo Hospital Displaced 4-part fractures of the proximal humerus carry a signif- 082 The Neer Classification of Fractures of the Proximal icant risk of avascular necrosis (AVN). Recent reports showed inci- Humerus dence of AVN insome subtype of 4-part fractures was low. The Shiono Shohei, Ogawa Kiyohisa, Ikegami Hiroyasu, Inokuchi Wa- purpose of this study was to show the new classification of the 4- taru, Nakamichi Noriaki, Tanji Atsushi, Department of Orthopaedic part fractures of the proximal humerus and to report the incidence Surgery, Keio University of AVN in each group. This study consisted of51 cases (37 females, Codman showed that fractures of the proximal humerus occurred 14 males) with 4-part fractures of the proximal humerus. The mean along the former lines of the epiphyseal and there were 14 types of age was 66.8 years old (range 29 to 88 years old).4-part fractures fracture. Neer classified 7 types of fractures into a 2-part, 3-part and without a dislocation were classified into 4 groups (valgus type, 4-part fracture (group 1) and this classification had a correlation varus type, split head type, other type). 4-part fractures with a dislo- with vasculality of the humerus head and selection of treatment pro- cation were classified into 4 groups (valgus impacted subcoracoid cedures. However, there are few reports about the other 7 types of type, displaced subcoracoid type, axillary type, posterior disloca- fracture (group 2) and there was no classification of the fractures. tion type). In the valgus group (18 cases; open reduction and inter- We studied 603 fractures of the proximal humerus in 603 cases nal fixation (ORIF): 12 cases, prosthetic replacement: 4 cases, by evaluating X-ray films. 266 were males and 337 were females. conservative treatment: 2 cases), no cases showed AVN. In the varus The average age was 52.6 years old (range: 18 – 99). We classi- group (8 cases), all cases were treated by ORIF, 1 case showed fied these fractures by Codman classification. 19 fractures (3.1%) AVN. In the split head group (4cases; ORIF: 3 cases, prosthetic re- came under group 2. They were (1)(HH:humerus head)+(GT:greater placement: 1 case), all 3 cases healed without AVN. In another tuberosity$LT:lesser tuberosity)+(shaft) 6 fractures, (2)(HH)+(GT$shaft)+ $ $ group (4 cases; ORIF: 3 cases, prosthetic replacement: 1 case), 2 (LT) 1 fracture, (3)(HH)+(LT shaft)+(GT) 7 fractures, (4)(HH shaft)+ cases showed AVN. The valgus impacted subcoracoid group con- (GT)+(LT) 3 fractures, (5)(HH$shaft)+(GT$LT) 1 fracture, (7) $ $ sisted of 6 cases (ORIF: 1 case (AVN(-)), prosthetic replacement: 5 (HH LT)+(GT shaft) 1 fracture.8 of these fractures came under cases), the displaced subcoracoid group consisted of 5 cases Neer’s minimally displaced type, 3 fractures Neer’s 2-part fracture (ORIF: 3 cases (1 case, AVN(+)), prosthetic replacement: 2 cases), and 8 fractures (1.3%) were not described in Neer classification. the axillary group consisted of 5 cases (ORIF: 1 case (AVN(+)), pros- Fractures that were not described in Neer classification were thetic replacement: 3 cases, resection: 1 case), and posterior dislo- rare (1.3%). We could manage these fractures respecting Neer’s cation had 1 case (prosthetic replacement). 4-part fractures without a dislocation were almost treated satisfactorily by ORIF without AVN. ORIF for 4-part fractures with a dislocation was challenging, but some cases may have healed without AVN by minimal invasive reduction and internal fixation.

084 Clinical Results of Displaced Proximal Humeral Fractures Morihara Toru, Horii Motoyuki, Takubo Yoshinori, Tachiiri Hisa- kazu, Iwata Yoshio, Honda Hiroaki, Namura Takehiko, Fujiwara Hiroyoshi, Kurokawa Masao, Kubo Toshikazu, Department of Or- thopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine (Purpose) We investigated the clinical results of displaced proximal humeral fractures treated by plate, anterograde wiring, retro- grade wiring and an intramedullary nail fixation. We evaluated the risk factors from the cases of complications occurred. (Materials and methods) one hundred and ten shoulders of 110 patients (26 males, 84 females, mean age 68 years old) underwent open surgery by pinning (28 cases), intramedullary fixation (62 cases) and plate fixation (20 cases). Fracture types were a 2 part A2 (44 cases), A3 (21 cases), 3 parts B1 (40 cases), and B2 (5 cases). From the clinical results we assessed the risk factors including age, fracture type and fixation method. (Results) Ten of 110 cases were cutout. The mean age was 68 years old (54-85). Six of 28 cases were pinning, 3 of 20 cases used a plate, and 2 cases of 62 the nail was cutout. In the type of fracture, 4 of 44 cases in A2, 5 of 21 cases in A3, 1 of 40 cases J Shoulder Elbow Surg Abstracts e13

in B1, and 1 of 5 cases in B2 were cutout. The cutout risk was signif- 087 Comparing the Long Head of the Biceps Changing in icantly increased in the pinning surgery, and the A3 fractures. In the Form to the Long Head of a Biceps Rupture with Rotator Cuff cutout rate of pinning the risk of fractures was significantly high. Tears (Conclusion) Cutout risk was significantly increased in the type Kobayashi Hirokazu, Kimizuka Kouichiro, Department of Orthopae- of unstable A3 fractures. Unstable A3 fractures were not suitable dic Surgery, Chushin-mastumoto General Hospital to pinning. Hata Yukihiko, Division of Rehabilitation Medicine, Shinshu Univer- sity School of Medicine Murakami Narumichi, Kato Hiroyuki, Department of Orthopaedic Surgery, Shinshu University School of Medicine A rotator cuff tear with the long head of the biceps (LHB) chang- 085 Intramedullary Fixation for Treatment of Proximal ing in form or LHB rupture are experienced frequently. This study in- Humeral Fractures vestigated the characteristics of the rotator cuff tears with the LHB 1 2 Sato Katsumi, Komatsuda Tatsuro, Koike Yoichi, Kumagai Jun, In- changing in form and a LHB rupture. 200 consecutive shoulders in oue Hisayosi,3 1. Department of Orthopaedic Surgery, Tohoku Ro- 197 patients who underwent rotator cuff repair were studied retro- sai Hospital, 2. Department of Orthopaedic Surgery, NTT East spectively. Out of these shoulders, LHB changing in form was iden- Tohoku Hospital, 3. Department of Orthopaedic Surgery, Ishino- tified in 48 shoulders in 48 patients (31 men and 17 women, the maki Red Cross Hospital changing in form group) and 14 shoulders in 14 patients (11 men The purpose of this study was to investigate the clinical results of and 3 women, the rupture group). The age of the patients ranged the internal fixation using Polarus humeral nails for fractures of the from 33 to 84 (mean 61.4) years old of the changing in form group proximal humerus. Ninety-three shoulders of 93 patients (20 males, and from 45 to 75 (mean 61.3) years old of the rupture group. Med- 73 females) underwent the intramedullary fixation using Polarus hu- ical histories and operative findings were compared between the meral nail from October, 2000 to May, 2006. Mean age was 69 changing in form and the rupture group. Additionally, the preoper- years old (50-92) at surgery and average follow-up period was ative and the postoperative results were evaluated using the JOA 7.8 months (3-14) after surgery. Fracture types were 2-parts (49 score. There was no significant difference between the changing shoulders), 3-prats (36 shoulders) and 4-prats (8 shoulders) by in form and rupture groups in age or gender, duration between Neer classification. We evaluated the pain score by JOA, the range time of injury and surgery and the JOA scores of the pre-operation of motion and postoperative complications in clinical results, and the and post-operation. Traumatic presence in the rupture group was bony union, the status of reduction at surgery and the varus defor- significantly more than that in the changing in form group (p < mity during postoperative course in radiological findings. All the pa- 0.05). There was no significant difference between the changing tients who underwent oateosynthesis obtained a bony union and in form and rupture groups in the size of the rotator cuff tear. Cases there was no osteonecrosis of the humeral head. The postoperative with a subscapularis tear in the changing in form group were signif- pain score was a mean 26 points (20-30) and the range of motion of icantly more than those in the rupture group (p < 0.05). Many of the the shoulder joint was a mean 119 degrees (40-180) in elevation, rotator cuff tears in the changing in form group had a few to trau- 36 degrees (-20-85) in external rotation and L2 (B-T6) in internal ro- matic presences and a large with subscapularis tear. We suggested tation. Clinical and radiological outcome of the proximal humeral that these appearances of the disease machine beginnings of the 2 fractures with Polarus humeral nail was satisfactory in 2-part, 3- groups were not the same. part and some of the 4-part fractures. Proximal screws in 20 shoulders had to be removed of backed out and/or impingement, but these complications were improved by a secure fixation with the locking screw. The intramedullary humeral nail can be one of the ef- 088 Characteristics of Muscle Strength in Shoulders with fective method for the treatment of proximal humeral fractures. Asymptomatic Rotator Cuff Tears Kikuchi Kazuma, Minagawa Hiroshi, Abe Hidekazu, Yamamoto Nobuyuki, Seki Nobutoshi, Division of Orthopaedic Surgery, De- partment of Neuro and Locomotor Science, Akita University School of Medicine 086 Clinical Evaluation of Hemiarthroplasty for Proximal Fukuta Masashi, Department of Orthopedic Surgery, Gifu University Humeral Fractures A Comparison of Acute and Chronic Cases School of Medicine Hirose Jun, Ide Junji, Tokiyoshi Akinari, Mizuta Hiroshi, Department Itoi Eiji, Department of Orthopedic Surgery, Tohoku University of Orthopaedic and Neuro-Musculoskeletal Surgery, Faculty of School of Medicine Medical and Phamaceutical Sciences, Kumamoto University Shoulders with rotator cuff tears were divided into 3 groups ac- Nomura Kazutoshi, Department of Orthopaedic surgery, National cording to pain: those who have pain at present (symptomatic Hospital Organization Kumamoto Medical Center group), had pain in the past but not at present (ex-symptomatic Watanabe Mitsunobu, Department of Orthopaedic Surgery, Konan group) and have not had pain (asymptomatic group). The purpose Hospital of this study was to clarify the differences in muscle strength among We studied the results of shoulder hemiarthroplasty. 9 patients (8 these 3 groups with isolated tears of the supraspinatus. There were females, 1 male) with proximal humeral fractures including 5 acute 31 shoulders in the symptomatic group, 21 in the ex-symptomatic fractures, a non-union of a surgical neck fracture, and 3 revisions for group and 66 in the asymptomatic group. The abduction strength the failure of osteosynthesis, were treated by hemiarthroplasty. Their and external rotation strength in adduction were assessed with the mean age was 69.4 years old (range 53 to 84 years old). The mean use of a manual muscle test and compared among the groups. Ab- follow-up period was 9 months (range, 6 to 23 months). Clinical out- duction weakness was observed in 52%, 33% and 38% in the symp- come was evaluated according to the Japanese Orthopaedic Asso- tomatic group, the ex-symptomatic group and the asymptomatic ciation (JOA) score. The mean JOA score was 61.5 (range 39 to 83 group, respectively. There were no significant differences among points). The operating time and bleeding were 2 hours 26 minutes them. Weakness in external rotation was observed in 52%, 10%, and 236 g, respectively. 2 of 3 patients with a revision had postop- and 39% in the symptomatic, ex-symptomatic, and asymptomatic erative complications. 1 had loosening of the stem and another had groups, respectively. External rotation strength was significantly a subluxation of the humeral head. Hemiarthroplasty of the shoulder weaker in the ex-symptomatic group than the others (symptomatic is a good surgery for the treatment of proximal humeral comminuted and ex-symptomatic group, p ¼ 0.002; ex-symptomatic and asymp- fractures in terms of pain relief. However, there was only moderate tomatic group, p ¼ 0.01). Well preserved strength in external rota- functional improvement especially in patients with a previous sur- tion is characteristic to ex-symptomatic shoulders with isolated tears gery than those with acute fracture. of the supraspinatus. e14 Abstracts J Shoulder Elbow Surg

094 The Learning Curve of an Arthroscopic Rotator Cuff Isshin, Takaoka Kunio, Department of Orthopaedic Surgery, Osaka Repair City University Graduate Schoolof Medicine Takeda Hiroshi, Department of Orthopaedics, Kumamoto Kinoh Delamination is 1 of the horizontal tears’ morphology observed Hospital in full-thickness rotator cuff tears. However, this pathology is not well Arthroscopic rotator cuff repair (ARCR) is a technically demand- known about in detail. The aim of this study was to investigate the ing procedure. The purpose of this study was to quantify the learning characteristics of delamination by arthroscopic evaluations. curve by analyzing the operative time. 180 cases of ARCR (mean We retrospectively evaluated arthroscopic findings in 162 pa- age 59 years old, range 21 to 79 years old, 127 males, 53 females) tients (100 males and 62 females) with arthroscopically treated were performed between March 2003 and February 2006 by a sin- full-thickness rotator cuff tears. The average age at the surgery gle surgeon. A subacromial decompression was added to all cases was 62.2 years old (from 31 to 79 years old). except those with massive tears. Suture anchors were used to repair Cofield’s classification for rotator cuff tear sizes: small, medium, the cuffs. If the cuff was mobile enough, the double row method was large and massive was used. Patients were divided into 3 groups as applied (49/180 cases, 27%). There were 20 partial thickness their age; the 30s and 40s were classified as group A (21 cases), the (11%), 47 small (26%), 69 medium (38%), 25 large (14%), and 50s and 60s were classified as group B (102 cases) and the 70s 19 massive tears (11%). The learning curve was analyzed with were classified as group C (39 cases). We evaluated the relation- the operative time. Also, the correlation of the operative time with ship between arthroscopic findings about delamination and each the number of suture anchors used and the size of the tear were eval- group. uated. Consecutive blocks of 20 cases were analyzed. The mean Delamination was observed in 60 cases (38 males and 22 fe- operative time and the standard deviation for the first block was males) (37.0%). 153 + 25 minutes (122 – 194 min.), and 72 + 21 minutes Delamination was not observed in 102 cases (62 males and 40 (42-112 min.) for the last block. At the third block (case number females) (63.0%). There was no statistical relationship between fre- 61-80), the mean operative time became less than 2 hours. The op- quency and gender. Frequencies of delamination in each tear size erative time decreased rapidly during the first 100 cases. The mean group were as follows. massive: 14/39 (36%), large: 9/20 number of the suture anchors used was 2.0, and it was correlated (45%), medium: 33/84 (39%) and small: 4/19 (21%). with the operative time (Spearman’s rho ¼ 0.43, p < 0.0001). There were low frequencies in the small size group compared to The size of the tear was also correlated with the operative time the larger size groups. (Spearman’s rho ¼ 0.39, p < 0.0001). The operative time rapidly Frequencies of delamination in each age group were as fol- decreased during the first 100 cases. The size of the tear and the lows:Group A: 10/21 (48%), group B: 37/102 (36%) and group number of suture anchors were correlated with the operative time. C: 13/39 (33%). There were high frequencies in the youngest age group compared to the older age groups. Frequencies of delamination was lowest in the small size tear group and it was highest in the youngest age group. 095 Arthroscopic Repair of Massive Rotator Cuff Tears Involving Subscapularis Tendon Ide Junji, Tokiyoshi Akinari, Hirose Jun, Mizuta Hiroshi, Department of Orthopaedic Surgery, Kumamoto University Hospital, Depart- ment of Orthopaedic Surgery, Graduate School of Medical Sci- ences, Kumamoto University 097 Functional and Structural Outcome after Arthroscopic Although rotator cuff tears are being repaired arthroscopically Rotator Cuff Repair - Serial Assessment of Postoperative Cuff with increasing frequency by orthopaedic surgeons, the arthro- Integrity by Traction-MRI scopic repair of subscapularis tears remains a challenge and only Komatsuda Tatsuro, Koike Yoichi, Sato Katsumi, Department of Or- few studies have examined treatment outcomes. The purpose of thopaedic Surgery, Tohoku Rosai Hospital this study was to evaluate the outcome in patients who underwent The purpose of this study was to reveal the functional outcome of the procedure. Our prospective study population consisted of 15 pa- arthroscopic rotator cuff repair and to evaluate the postoperative tients, 11 males and 4 females, whose mean age was 62 years old cuff integrity by traction-MRI. 47 shoulders (39 males, 8 females, (range 52 - 69 years old). The mean duration of follow-up was 33 mean 57 years) were included. All 47 tears (35 complete type months (range 25 - 60 months). All had a full-thickness tear of the (10 small, 21 medium, 4 large), 12 incomplete type (9 bursal- subscapularis tendon; 10 had a concomitant supraspinatus tear, side, 3 articular-side)) were repaired using the single-row technique. and 5 had concomitant supraspinatus and infraspinatus tears. The The mean follow-up period was 31 months (range 17-48) and the shoulders were evaluated using the JOA score. An arthroscopic su- clinical outcome was assessed using the JOA score. Postoperative ture anchor technique was used for the repair. After arthroscopic re- cuff-integrity was evaluated by traction-MRI, performed at both 4 pair, the mean JOA scores significantly improved from 54.4 points and 12 months postoperatively. MR findings of T2WI were classified to 90.1 points (p < 0.0001). Rated on the JOA scale, the outcomes into 3 categories (low, intermediate and high). On MRs, low signals were excellent in 8 patients, good in 5, fair in 1, and poor in 1. Pre- were observed in only 21% at 4 months but increased significantly operatively, 12 patients had a positive- and 1 a negative lift-off test; to 53% at 12 months. Intermediate signals were seen in tendons in 2 patients could not be tested as they had a restricted range of inter- 63% of the shoulders at 4 months and in 37% at 12 months. High nal rotation. The belly-press test was positive in 14 and negative in 1 signals were seen in tendons in 16% of the shoulders at 4 months. patient. Postoperatively, 3 patients had a positive and 12 a negative This rate decreased to 11% at 12 months. In the shoulder joint, lift-off test; 4 had a positive and 11 a negative belly-press test. Ar- high signals were seen in 56% at 4 months, the rate which de- throscopic repair of subscapularis tears using the suture anchor tech- creased to 26% at 12 months. In the bursa, high signals were nique is a safe and effective procedure with respect to the alleviation seen in 74% at 4 months and 63% at 12 months. The average total of shoulder pain and the improvement of function and range of JOA score improved from 66.2 (pain: 9.1, function: 14.8, ROM: motion. 23.6) to 93.5 (pain: 27.2, function: 19.5, ROM: 26.7) in all the cases, from 65.5 to 95.9 in the low group, from 66.6 to 94.9 in the intermediate group and from 68.4 to 76.8 in the high group. The functional outcome of this procedure was quite satisfactory. 096 Arthroscopic Evaluations of Delamination in Full- MR findings revealed serial signal changes after surgery, which sug- thickness Rotator Cuff Tears gested the morphologic improvement at the tendon-bone junction. Nakano Motohiro, Ito Yoichi, Tomo Hiroyasu, Nakao Yoshihiro, Na- This study suggested that better functional outcome may be estab- kamura Nobuyuki, Manaka Tomoya, Naka Yoshifumi, Matsumoto lished in shoulders with better postoperative cuff integrity. J Shoulder Elbow Surg Abstracts e15

098 Relationship between Post-operative Changes of 104 Clinical Results of Arthroscopic Dual-Row Rotator Cuff Shoulder Muscle Strength and Cross-sectional Area of the Repair for a Rotator Cuff Tear Rotator Cuff Muscle Horigome Keiko, Department of Orthopaedic Surgery, Asahikawa Ishitani Eiichi, Matsuura Koumei, Department of Orthopaedic Sur- Kosei Hospital gery, Kitakyushu Municipal Wakamatsu Hospital Okamura Kenji, Hirose Hiroaki, Yamamoto Noriyuki, Gouroku Ta- The purpose of this study was to evaluate the changes with time kahiro, Department of Orthopaedic Surgery, Sapporo Medical Uni- of the muscle strength of the shoulder and the cross-sectional area versity (CSA) of rotator cuff muscle after arthroscopic rotator cuff repair The purpose of this study was to evaluate the clinical results after (ARCR) and to investigate the relationship between the tear size of arthroscopic rotator cuff repair using the dual-row technique (ARCR- rotator cuff and the muscle strength and CSA before ARCR. We in- DF) for full-thickness rotator cuff tears. We evaluated 11 patients (10 vestigated 20 cases (13 males and 7 females). The mean age at op- males and 1 female) repaired by the dual-row technique, from No- eration was 63.5 years old (54 - 78). Pre and post – operative vember 2004 and were consequently followed-up for more than 1 muscle strength and CSA were compared at 6 months and 1 year year postoperatively. The affected shoulder was on the right side after the operation. We measured the longest anterior posterior di- in 10 patients and on the left side in 1 patient. The average age ameter (a) and the longest transverse diameter (b) among the find- at operation was 60.3 years old (36 to 75 years old); the mean ings at the operation. pre-operation period was 11.3 months (0.5 to 48 months); and 11 cases were S size classified in a & 2cm and b & 2cm, 9 the mean follow-up period was 15.3 months (12 to 23 months). cases were L size classified in a > 2cm and b > 2cm. We performed The tear type was small in 1, medium in 6, and large in 4. We arthro- 3 tests as abduction, 2 tests as external rotation and internal rota- scopically performed subacromial decompression and sutured the tion. We evaluated the isometric muscle strength of the shoulder us- torn cuff to the greater tuberosity using suture anchors according ing MICROFET. Some physical therapists did these tests 3 times and to the dual-row technique. We put the arm on a shoulder abduction the results were averaged. brace for 4 weeks. For a clinical follow-up, we used the Japanese The results were divided by the value of the pre-operative unaf- Orthopaedic Association score (JOA score). According to the JOA fected side. We measured the CSA of supraspinatus, infraspinatus, score, the average total score increased from 69.6 points to 96.8 teres minor and subscapilaris at a slice 1cm medial to the gleno-hu- points. The average scores of pain, function, and motion improved meral joint with an MRI oblique-sagittal view of T2. from 10.9 to 28.2 points, from 16.2 to 20 points, and from 23.2 to We used the values that divided the CSA by the head of the hu- 28.8 points, respectively. We evaluated the shoulder muscle merus area to eliminate any individual difference. strength. The average abduction strength increased from 3.38 6 The muscle strength gradually recovered after operation regard- 2.48kg to 6.1 6 2.26kg. The average external rotation strengths less of tear size. at the side and at the 90 degree abduction increased from 4.33 The strength of external rotation showed statistically significant 6 2.68kg to 8.11 6 2.22kg, and 4.58 6 3.13kg to 9.18 6 changes at 6 months after the operation. 2.53kg, respectively. We also evaluated the postoperative MRIs. The strength of abduction and internal rotation showed a mean- Postoperative MRIs showed 18.2% of re-torn cuff. The clinical out- ingful recovery 1 year after the operation. come of the ARCR-DF was almost satisfactory, but patients with large On the other hand, the CSA did not show any significant tears tend to retear. changes after the operation. The pre-operative muscle strength of abduction and external rotation were significantly correlated with the tear size. 106 Outcome of Arthroscopic Rotator Cuff Repair for Tears over 2-cm in Coronal Dimension: A Comparison of Repair with Alternative Methods of Mobilization and Fixation Shimokawa Kanichi, Ito Hitoshi, Department of Orthopaedic Sur- 101 Experiences of Arthroscopic Rotator Cuff Repair gery, Omachi Municipal Hospital Kanbe Katsuaki, Inoue Kazuhiko, Inoue Yasuo, Department of Or- The purpose of this study was to clarify the clinical and anatomic thopaedic Surgery, Tokyo Women’s Medical University, Medical outcome of arthroscopic rotator cuff repair (ARCR) with alternative Center East repair methods for patients who had a full-thickness tear measuring Excellent results of arthroscopic rotator cuff repair have been re- over 2 cm in coronal dimension. Sixty-eight consecutive patients of ported recently. However, a skillful arthroscopic technique may be 1 full-thickness, chronic retracted rotator cuff tears that had had tears of the factors to lead to this excellent outcome. We treated rotator measuring over 2 cm in coronal dimension grouped to two of the fol- cuff tear arthroscopically 38 shoulders of 37 patients. To clarify lowings. In group A (38 cases, 20 men and 18 women, whose av- the results of our cases, we investigated the outcome of surgery by erage age was 65.4 years old), a retracted cuff was released and JOA scores and MRI. The patients included 24 males, 13 females mobilized intensively, especially released from the coracoid base with a mean age of 64 (23-79) years old. The mean follow-up period followed by an interval slide technique and fixed to its footprint using was 15 months (8-27 months). A complete tear was in 14 shoulders a double-row anchor method without excessive tension. Group B including 3 small, 5 medium, 4 large and 2 massive rotator cuff consisted of 30 cases, 16 men and 14 women, whose average tears. An incomplete tear was in 24 shoulders including 5 gleno- age 65.3 years old, received standard ARCR by ordinary cuff re- hiumeral joint side, 19 subacromial bursal side. We performed lease and most single-row anchor repair. Metallic screw-in-type su- a double-row method for a rotator cuff tear using suture anchors. ture anchors were used on bone to tendon fixation in all the A PTFE felt patch was used for massive rotator tears. Arthroscopic patients and the postoperative rehabilitation was performed in the subacromial decompression (ASD), debridement and side to side su- same regimen. The average tear size in the coronal dimension tures were performed for incomplete tears. The JOA score had im- was 3.6 cm in group A and 3.3 cm in group B, with no difference proved from an average of 57.5 to an average of 87.2. MRI in the 2 groups. The clinical outcome was evaluated using the Japa- findings after 15 months were type I, 2 shoulders, type II, 4 shoul- nese Orthopaedic Association’s (JOA) shoulder score, muscle ders, type III, 4 shoulders, type IV 2 shoulders and type V, 2 shoul- strength, pain and range of motion. The anatomic outcome was ders. The Re-rupture rate was 28.6%(4/14) by MRI including 3 evaluated using T2-weighted magnetic resonance imaging (MRI) cases of large tear. ASD and side to side suture was effective for classification after Sugaya. An average postoperative follow-up pe- an incomplete tear. A PTFE patch had excellent clinical results. riod was 12.5 and 17.4 months respectively. All patients improved Therefore, we need to analyze a more effective arthroscopic skill after surgery on pain, JOA shoulder score, range of motion and mus- of large rotator cuff tear in the future. cle strength. However, no statistical difference of clinical indicators e16 Abstracts J Shoulder Elbow Surg

was seen between both groups. A postoperative re-tear observed 112 The Radial Plane of MR Arthrogram for Labral Lesions of less frequently in group A (15.8% versus 33.4%), but without any the Shoulder statistical difference. The tension-free double-row fixation with suffi- Mondori Takamitsu, Department of Orthopaedic Surgery, Jyonai cient mobilization by intensive release of the cuff will present a lead- Hospital ing solution to prevent re-tear of the repaired ten. Midorikawa Koji, Department of Orthopaedic Surgery, Kawanami Hospital The purpose of this study was to investigate the efficiency of radial plane of MR arthrogram (R-MRA) for labral lesions of the shoulder. 64 shoulders were examined and all patients had either signs 108 Clinical Efficacy and Limits of Arthroscopic Subacromial and symptoms of labral lesions. There were 53 men and 11 women, Decompression with Intraarticular Debridement for a Massive aged 15-45 years old (mean, 21.5 years old), with 48 right and 16 Rotator Cuff Tear left shoulder abnormalities. The patients were referred to us because Sakai Kiyoshi, Department of Orthopaedic Surgery, Toyama Red of a recurrent dislocation (32 cases), a superior labral abnormality Cross Hospital (24 cases), a traumatic first dislocation (6 cases), a recurrent dislo- We reported on the clinical efficacy and limits of arthroscopic cation with a superior labral abnormality (2 cases). Each patient un- subacromial decompression (ASD) with intraarticular debridement derwent R-MRA after intra-articular injection of 10ml of 0.5% for a massive rotator cuff tear. A chart review of 24 shoulders of mepivacaine. R-MRA was performed with 1.0-T system (Siemens 21 patients with a massive rotator cuff tear, all of them showed Harmony). All patients were supine with the humerus in the neutral good elevation after a lidocaine injection into the subacromial position. After a radial localizing imaging, intensity and morpholog- bursa, and who were treated by ASD with intraarticular debride- ical changes in the labrum through all the o’clock positions of the gle- ment was undertaken. The clinical outcome was measured by the noid rim in T2 star images by the FRASH method were evaluated. Japanese Orthopedic Association Shoulder Score (JOA score). Labral lesions of all patients were categorized according to Kim The average age of this study was 72.5 years old. All the patients and Yamasaki’s classification, and the findings on the R-MRA were showed good relief of night shoulder pain and an increase of the correlated with the arthroscopical findings. This study showed range of active shoulder elevation. 21shoulders of 19 patients 68% of sensitivity, 92.7% of specificity, and 82.7% of accuracy were satisfied with the surgery because of pain relief. 3 shoulders through all the o’clock positions of the glenoid rim on the radial of 3 were not satisfied. The reasons were, pain remaining in heavy plane of MRA. A radial MRA was useful to diagnose the labral lei- work of a 64 year old woman, delicate difference of pain remission sion of the shoulder precisely and from all viewpoints. Though between bilateral shoulders of a 70 year old man who had under- 0.5% mepivacaine is cheaper than gadopentetate meglumine, it gone the same operation, and pain remaining on elevation with se- did not influenced the enhancement effect. vere shoulder osteoarthritis of a 81 years old woman. In a massive rotator cuff tear patients showing good pain relief elevations after a subacromial bursal block, were those who did not need to work 114 The Evaluation of Postoperative MRI for a Rotator Cuff heavily, ASD with inatraarticular debridement provided good pain Repair relief improvement of shoulder elevation. Goto Hideyuki, Horiuchi Osamu, Hisazaki Shinji, Otsuka Taka- nobu, Department of Orthopaedic Surgery, Nagoya City University Medical School Sugimoto Katsumasa, Department of Orthpaedic Surgery, Meitetsu Hospital 111 Analysis of Scapular Motion in Abnormal Shoulders Takeuchi Hiroyuki, Takeuchi Orthopaedic and Internal Medicine Using ‘‘Wing view’’ Clinic Tomo Hiroyasu, Ito Yoichi, Nakao Yoshihiro, Manaka Tomoya, The purpose of this study was compare the integrity of the rotator Naka Yoshifumi, Nakamura Nobuyuki, Nakano Motohiro, Matsu- cuff between the post operative MRI within 3 months and the MRI at moto Isshin, Takaoka Kunio, Department of Orthopaedic Surgery, final follow-up for a rotator cuff repair. In this study, 20 cases of par- Osaka City University Graduate Medical School tial to large rotator cuff tears were treated by either arthroscopic (15 Purpose: We reported on a novel radiogram, ‘‘Wing view’’ for cases) or mini-open rotator cuff repair (5cases). The mean age of all nd the evaluation of scapular motion in normal shoulders at the 32 cases was 64.1 years old. The postoperative MRI was performed at JSS annual meeting. The aim of this study was to analyze the scapu- the time within 3 months and 1 year after surgery. The rotator cuff lar motion in abnormal shoulders with Wing views and to evaluate integrity was evaluated by means of Sugaya’s classification. The the pathology. Methods: We evaluated Wing views of 45 patients: post operative findings of MRI within 3 months were classified as 11 massive rotator cuff tears, 18 frozen shoulders and 16 recurrent Type I : 0, Type II : 5, Type III : 2, Type IV : 8, Type V : 5, respectively. dislocations of the affected shoulders with the other healthy shoul- The final follow-up findings of MRI were classified as Type I : 4, ders. The average age of the time of the evaluation was 50.0 (17- Type II : 2, Type III : 3, Type IV : 6, Type V : 4, showing morphological 76) years old. Shoulders were postured in 3 ways: (1) 0 degree of improvement of the rotator cuff configuration. In conclusion, the horizontal adduction, (2) 90 degrees of horizontal adduction and present study shows that the signal intensity of the rotator cuff de- (3) maximal horizontal adduction. We measured 2 parameters by tected by postoperative MRI had a changed time course. computerized image analysing software. SS: the angles between the spinal process and medial edge of the scapular, ST: anterior inclination angles of the scapula. We evaluated 2 parameters in 3 shoulder positions and statistically analysed comparison between the 115 Postoperative Changes of MRI Findings over Time after affected shoulder and the healthy shoulder. Results: Wing view ra- Rotator Cuff Repair diograms of 9 massive rotator cuff tears, 15 frozen shoulders and Oizumi Naomi, Suenaga Naoki, Hisada Yukiyoshi, Minami Akio, 14 recurrent dislocations were eligible for evaluation. 7 patients Department of Orthopaedic Surgery, Hokkaido University School were inadequate for analysis, because of posture difficulties. SS of of Medicine the affected shoulders in massive rotator cuff tears and frozen shoul- Fukuda Kimitaka, Department of Orthopaedic Surgery, Tonan Hos- ders were significantly higher compared to those of the healthy shoul- pital Sports Center ders. STof the affected shoulders was significantly higher in the same Although MRI has been proved effective in diagnosing a re-rupture manner in those shoulders. Conclusion: The scapula moves more an- of repaired rotator cuff tendon, there are only a few studies about the tero-laterally in massive rotator cuff tears and frozen shoulders. signal changes of the repaired tendon over time. The objective of this J Shoulder Elbow Surg Abstracts e17

study was to follow the changes of the MRI findings of the repaired cuff has been expanding as well as to the lower extremities. However, tendon over 1 year. Twenty-two shoulders, which received open ten- conventional intramedullary nailing has problems in reduction and don-to-bone repair by a pull-out method and acromioplasty, were fixation in some fracture types. This paper reports on the method evaluated with MRI postoperatively at least twice within 1 year and and clinical results of our treatment using intramedullary nailing over 1 year. There were 10 males and 12 females; their age at the op- and transmedullary support screws combined together. During the eration was 50-80 years old (average: 63.8). There were 6 incom- period between 2003 and 2006, we had 12 cases (males5, fe- plete, 3 small, 6 medium, 3 large, and 4 massive tears. MRI was males7) of intramedullary nailing combined with transmedullary performed on an 0.5-T system and T2-weightened images were ob- support screw use for the fracture of the humerus, of which 6 cases tained. Intensity of the tendon or the bone-tendon interface was de- were fresh and 6 were non-union after conservative treatment at for- fined as ‘high’ when it was as high as joint fluid, as ‘low’ when it mer clinics. All the cases had the fracture lines running spirally or was the same as the normal tendon, and as ‘medium’ when it was obliquely. The average age of the patients was 60 (42-69 years between ‘high’ and ‘low’. The follow-up period was 12-106 months old), the average follow-up period was 22 months (3-40 months). (average: 21.8). The re-rupture rate was 18% in the whole and We studied these 12 cases about fracture types and treatment 27% in the large and massive tears. In 6 shoulders which showed methods and evaluated the results with x-rays and from the ROMs ‘low’ within 1 year, 5 remained ‘low’ and 1 changed to ‘high’ at of the shoulder and elbow joints. As for fracture types, there were the final follow-up. In 10 shoulders which showed ‘medium’ first, 2 three 11-A3.1, two 11-A3.2, five 12-A1.1, two 12-A2.1 cases by remained ‘medium’, 7 changed to ‘low’, and 1 changed to ‘high’ OTA classification. As for the insertion point of the deltoid, seven finally. In 6 shoulders which showed ‘high’ first, 3 remained ‘high’, cases were at the proximal fragment, and five at the distal fragment. 1 changed to ‘low’, and 2 changed to ‘medium’ finally. The JOA We used transmedullary support screws in the proximal fragment in scores significantly improved from 43.5-88 points (average: 63.1) eight cases, and in the distal fragment in four cases. Among six non- preoperatively to 75-100 points (average: 93.1) postoperatively. union cases, we transplanted the iliac bone in only one case. We ob- There was no correlation between the size of the tear and the intensity. served bone-union in all the cases. The ROM was the same as the In 50% of the cases, high intensity changed to low over 1 year. There- non-affected side in eight cases, however we observed limitation fore, it is suggested that high intensity of the tendon within 1 year after of external rotation and elevation of the shoulder joint in four cases. repair does not necessarily mean a re-rupture. In 1999, Krrettek reported on a method using screws around intramedullary nails by the name of Poller screws. This method has been mainly applied to fractures of the tibia and femur, however it is an effective method also for spiral or oblique fractures in proximal 116 Clinical Results of Internal Fixation for Proximal Humeral metaphysis as long as you keep a close watch on the insertion of the Fracture using the Targon PH Nail Ô humerus and the type of fracture. Sato Hideki, Nagao Akihiko, Department of Orthopaedic Surgery, Aomori Rosai Hospital Miura Hitoshi, Department of Orthopaedic Surgery, Asunaro Med- ical and Health Care Center 127 Surgical Outcome of Arthroscopic Bankart Repair with The purpose of this study was to evaluate the clinical results of the a Knotless Suture Anchor osteosynthesis for proximal humeral fractures using the Targon PH Nakamura Nobuyuki, Ito Yoichi, Tomo Hiroyasu, Nakao Yoshihiro, nail Ô. 22 patients underwent osteosynthesis using the Targon PH Nakano Motohiro, Manaka Tomoya, Naka Yoshifumi, Matsumoto nail from 2003 to 2005. 15 of these patients were followed up Isshin, Takaoka Kunio, Department of Orthopaedic Surgery, Osaka for more than 6 months (range, 6 to 37 months) after surgery. The City University Granduate School of Medicine average age at surgery was 69.7 years old. According to the AO Arthroscopic Bankart repair is one of the useful surgical proce- classification, 3 fractures were classified as A2.1, 2 as A2.2, 3 as dures, but there were problems with the difficult surgical technique A3.1, 2 as B1.2, 1 as B3.1, 3 as C3.1, and 1 as C3.1. The clinical and recurrence rate. Lately the knotless anchor was developed, results were evaluated based on the JOA score and the UCLA score. and convenience of arthroscopic surgery was reported on. The Postoperative osteoarthritc changes were radiographically classi- aim of this study was to evaluate the clinical results after a Bankart fied into 4 stages. All the patients obtained a bony fusion. The repair with a knotless anchor and to examine the utility for this mean postoperative JOA and UCLA scores were 88.4 (range, more than 1 year later. 59.5 to 100) and 31.6 (range, 22 to 35), respectively. The mean We evaluated 30 shoulders treated by arthroscopic Bankart re- range of shoulder flexion and external rotation was 136 degrees pair with a knotless anchor (22 men and women 8). The average (range, 85 to 165) and 50 degrees (range, 20 to 80), respectively. age at operation was 27.6 years old (15-58 years old). The average Postoperative osteoarthritic changes were graded into early stage in follow-up after an arthroscopic Bankart repair was 17.5 months (12 2 cases, advanced stage in 2 cases, and the end stage in 1 case. In to 35 months). A 1st time dislocation was the cause of injury in all 10 cases, no osteoarthritic change was seen. Metaphyseal commi- cases, and working hand. The non-working hand did not have this nution was associated with advanced or end stage osteoarthritis. abnormality. The Bankart repair was performed using 3-4 knotless Our results showed osteosynthesis using a Targon PH nail is a reli- anchors. We evaluated the Rowe scores of the last investigation able treatment for proximal humeral fractures. It was very important and the ROM. to position the proximal end of the nail the just below the subchon- We did not recognize a re-dislocation, but 2 shoulders had a sub- dral bone to insert multiple screws into the humeral head in the luxsation (6.7%) out of 30 shoulders. The average Rowe score was case of a metaphyseal comminution. stability 46.0 points, motion 19.2 points, function 28.8 points, 94.0 points in total. The average of operation side was 103.5, non-operation side was 108.7, and the ratio was 95%. We got good clinical results more than 1 year postoperatively. 118 The Clinical Applications of Transmedullary Support Screw for the Fracture of the Proximal Part of the Humerus Ikegami Hiroyasu, Nakamichi Noriaki, Kobayashi Shuuzo, Ogawa Kiyohisa, Department of Orthopaedic Surgery, School of Medicine, 128 A New Fixation Method of Arthroscopic Bankart Repair Keio University Technique : Double Bridging Fixation Method Naniwa Toyohisa, Department of Orthopaedic Surgery, Shiseikai- Hirata Masazumi,1 Morihara Toru,1 Iwata Yoshio,1 Honda daini Hospital Hiroaki,1 Kubo Toshikazu,1 Kurokawa Masao,2 Horii Motoyuki,3 In the wake of recent improvement of intramedullary nails, the 1. Department of Orthopaedics, Graduate School of Medical Sci- application of intramedullary nailing to a fracture of the humerus ence, Kyoto Prefectural University of Medicine, 2. Department of e18 Abstracts J Shoulder Elbow Surg

Orthopaedic Surgery, Saiseikai Suita Hospital, 3. Department of operated on in the beach-chair position under general anesthesia. Orthopaedic Surgery, Kyoto Interdisciplinary Institute Hospital of In 1 case, an anchor was inserted in an incorrect position. In certain Community Medicine other cases, the strands were displaced from the anchors and were Nowadays, single layer fixation of inferior glenohumeral liga- loosened. 2 anchors interfered with each other. After the induction mament (IGHL) -labral complex is commonly accepted at arthro- of anesthesia, the patients were seated on a surgical table; their scopic Bankart repair using suture anchor technique. Using this blood pressure at that time declined. During the procedure, the conventional method, the complex was repaired by pin point fixa- head of 1 patient shifted from its original position on the surgical tation and edge slack phenomenon after surgery was reported. We in- ble, depriving the head of support; this led to a practical dislodging troduce a new repair technique that provides double layer foot print of the tracheal tube. After the surgery, we observed both alopecia at fixation using PANALOK LOOP anchorÔ. After resurfacing the gle- the site of external occipital protuberance and axillary nerve palsy. noid rim, we added another suture through eyelet loop (suture A,B) All failures and complications occurred in the 1st 5 cases. The num- and inserted the anchor on the glenoid at the 5 o’clock position. Mo- ber of occurrences decreased with experience in further cases. After bilized IGHL-labral complex was conventionally fixed by the suture we performed the surgery in 20 cases, there were no failures or com- A. Second anchor with two sutures (suture C,D) was placed under plications. Thus, performing the arthroscopic Bankart procedure us- the glenoid at the 4 o’clock position. Both of the sutures were passed ing suture anchors is difficult for beginners. Based on these findings, through the IGHL-labral complex using suture relay technique. The generally, technical failure and complications occur in the first 5 suture B and C were tied outside the portal and the knot was placed cases in particular. Therefore, beginners should perform their first on the complex. Another ends of the suture B and C were tied on the 5 cases of the arthroscopic Bankart procedure using suture anchors complex by non-sliding knot. Third anchor with two sutures (suture under the supervision of an expert surgeon. E,F) was inserted on the glenoid at the 3 o’clock position. Suture D and E were tied in a same manner. Using this new technique named double bridging fixation method, double layer foot print fixation of IGHL-labral complex was achieved. This method is consid- 131 A Comparison of Modified Inferior Capsular Shift ered to be a useful and a further follow-up is required. Method Versus Arthroscopic Bankart Suture Repair for Recurrent Anterior Dislocation (Subluxation) of the Shoulder Shitara Hitoshi, Takagishi Kenji, Suzuki Hideki, Osawa Toshihisa, Isikawa Takashi, Aramaki Masayuki, Aiba Sachiko, Kobayashi Tsu- 129 Arthroscopic Bankart Repair with a Double Anchor tomu, Shinozaki Tetsuya, Department of Orthopaedic Surgery, Footprint Fixation (DAFF) Technique -A Preliminary Report Gunma Graduate School of Medicine Mizuno Naoko,1 Yoneda Minoru,2 1. Department of Orthopaedic The purpose of this study was to compare patients with recurrent Surgery, Yukioka Hospital, 2. Shoulder and Sports Medicine Ser- anterior dislocation and subluxation of the shoulder who were vice, Osaka Kosei-nenkin Hospital treated with a modified inferior capsular shift method with those Although arthroscopic techniques for anterior shoulder instabil- treated with an arthroscopic Bankart suture repair. ity have generally yielded good results and decreased the morbid- 51 shoulders were surgically treated. The patients were divided ity, a recurrence has been the most serious postoperative into 2 groups. In group M (21 shoulders), modified inferior capsular complication. In 2005 we developed a new type of arthroscopic shift method was performed, and in group B (30 shoulders), arthro- Bankart repair: the double anchor footprint fixation (DAFF) tech- scopic Bankart suture repair was performed. The groups were homo- nique. It simulates a conventional open transosseous Bankart repair. geneous in gender, dominance, age, age at 1st dislocation The purpose of this study was to introduce this technique and evalu- (subluxation), number of dislocations or subluxations, time elapsed ate the short-term surgical results. We investigated 45 shoulders (34 between 1st dislocation (subluxation) and surgery. The average fol- males and 11 females) which underwent a DAFF technique. The low-up for group M was 15.1 months, and for group B, it was 17.7 mean age at operation was 24.1 years old and the mean postoper- months. The postoperative rehabilitation was the same in both ative follow-up period was 13 months. DAFF technique was con- groups. Follow-up evaluations included JOA, Constant, JSS-SSI, sisted of a trough preparation and double anchor footprint fixation Rowe shoulder scores and limitation of range of shoulder motion. in order to make a larger area of the footprint repair. The shoulders Statistical analysis of data was performed using Welch’s t test (signif- had their internal rotation immobilized for 3 weeks after the opera- icance for p < 0.05). In group M, one of the 21 patients had expe- tion. We evaluated the postoperative range of motion, return to rienced apprehension in the follow-up period, but no patients had sports, recurrence and JSS shoulder instability score. Regarding a dislocation. In group B, 2 (6.7%) of the 30 shoulders experienced the postoperative range of motion, elevation recovered early, but ex- a dislocation. The follow-up JOA, Constant, JSS and Rowe shoulder ternal rotation could not recover so early. More than 12 months after scores of the 2 groups were not significantly different. The only signif- the operation, 23 patients completely returned to sports, 5 patients icant difference seen between the 2 groups was for range of motion returned partially. There was no recurrence of a dislocation. The JSS- evaluation with the Constant score and JSS-SSI score. The mean SIS improved from 52.9 preoperatively to 94.9 postoperatively. An value for group M was significantly greater than that for group B arthroscopic Bankart repair with a DAFF technique could be per- (Constant; p ¼ 0.036, JSS; p ¼ 0.028,). Though the follow-up re- formed successfully. We need a long-term follow-up and to study ported was short, arthroscopic Bankart suture repair was an effective more about the time of starting ROM exercises. surgical technique as well as the modified capsular shift method. In our study, Bankart suture repair was superior for an internal rotation and flexion than a modified inferior capsular shift method. 130 Arthroscopic Bankart procedure: Technical Failure and Complications Nishihara Hirohiko, Toga Hidekazu, Shiba Nobumasa, Sate Tat- 133 Arthroscopic Findings after a Bristow Procedure with suo, Seike Koji, Department of Orthopaedic Surgery, Tokyo Metro- a Capsulolabral Reconstruction of the Anterior Capsule politan Police Hospital Takubo Yoshinori, Nakagawa Haruhiko, Department of Orthopae- The purpose of this study was to evaluate the technical failure of dic Surgery, Otsu Municipal Hospital and complications during an arthroscopic Bankart repair using su- Morihara Toru, Iwata Yoshio, Honda Hiroaki, Kubo Toshikazu, De- ture anchors for recurrent anterior dislocation of the shoulder. This partment of Orthopaedics, Graduate School of Medical Science, procedure was performed between January 2004 and August Kyoto Prefectural University of Medicine 2006 on 34 patients comprising 28 males and 6 females with an Kurokawa Masao, Department of Orthopaedic Surgery, Saiseikai average age of 33.5 years old (range, 19–68); the patients were Suita Hospital J Shoulder Elbow Surg Abstracts e19

Anterior inferior glenohumeral ligament (AIGHL) is important for There are numerous reports of success with an open Bankart re- the anterior stability of the shoulder. As to the operation for anterior pair, using low recurrence of dislocation. Few studies indicate that instability of there shoulder without sufficient AIGHL, we have per- subscapularis (SSC) tenotomy may result in postoperative SSC insuf- formed the Bristow procedure with the capsulolabral reconstruction ficiency. The purpose of this research was to measure the subscapu- of anterior capsule (modified Bristow procedure). Several reports laris muscle strength, muscle area and signal intensity by magnetic have described that the clinical results after a modified Bristow proce- resonance imaging after the open Bankart procedure. dure were better than those after a Bristow procedure. To clarify the A total of 22 patients were observed prospectively for a mean reasons, we investigated the arthroscopic findings 1 year after our of 33 months (range 17-51 months). There were 11men and modified Bristow procedure. We examined 13 patients (13 shoul- 1woman. The mean patient age at the surgery was 22.8 years ders, 10 males and 3 females) who underwent modified Bristow pro- old (range, 18-36 years old). All patients were right-handed. 8 pa- cedures. Their mean age was 28 years old (range, 17-47 years old). tients had injured their shoulder of their dominant extremity. Internal In their 1st-time arthroscopy, AIGHL was considered insufficient in all rotation (IR) at 45 degrees abduction was at 60 degrees per sec- cases, and they all underwent modified Bristow procedures. 1 year ond. The peak torques of both extremities was measured at the after the operation, an arthroscopy was performed in the lateral- day before the operation, 6 months and 12 months after the oper- position under a general anesthesia. The relationship between their ation. We calculated the ratio of the affected side to the unaffected intraarticular findings and clinical results were evaluated. In 12 side. The peak torques of ER and IR of the pre-operation were cases (92%), a tissue like glenohumeral ligament was detected in ar- 13.5% and 18.5% respectively lower than those of the unaffected throscopy. In this study, we clarified that the tissue like glenohumeral side. The peak torques of ER and IR that were measured at 6 months ligament regenerated after a modified Bristow procedure in almost after the operation were 27.6% and 21.1% respectively lower than all cases, in which AIGHLs were insufficient at the 1st time arthros- those of the unaffected side. The peak torques of ER and IR that were copy. Even if AIGHL was insufficient, the capsulolabral reconstruc- measured at 12 months after the operation were 18.4% and 0.2% tion of the anterior capsule may result in the regeneration of AIGHL. respectively lower than those of the unaffected side. The area at 12 months after surgery was not significantly different from the preoperative area. However, the signal intensity at 12 months after surgery was significantly higher than that in the preoperative signal 134 The Long Term Results of the Bankart and Modified intensity. An open Bankart procedure using an L-shaped tenotomy Bristow Procedure for Recurrent Anterior Dislocation of the approach did not decrease SSC muscle strength and volume. This Shoulder procedure approach may lead to the deterioration of the subscapu- Ueno Shigekazu, Takada Junichi, Imoto Kenshi, Department of Or- laris muscle. thopaedic Surgery, Chitose city hospital Okamura Kenji, Hirose Toshiaki, Department of Orthopaedic Sur- gery, Sappro Medical University Yamamoto Nobuyuki, Department of Orthopaedic Surgery, Univer- sity of Akita 136 Diagnostic Value of Gerber’s Lift-off Test for Traumatic We wish to report on the long-term postoperative results of Shoulder Instability Cases 1 2 1 a Bankart and modified Bristow procedure for the treatment of recur- Kubota Suguru, Hata Yukihiko, Murakami Narumichi, Kobaya- 3 1 2 rent anterior shoulder dislocation. There were 27 patients (27 shoul- shi Hirokazu, Ishigaki Norio, Nakamura Kouichi, Kato Hir- 1 ders) who had undergone a Bankart and modified Bristow oyuki, 1. Department of Orthopaedic Surgery, Shinshu University procedure for the treatment of recurrent anterior shoulder disloca- School of Medicine, 2. Division of Rehabilitation Medicine, Shinshu tions at our clinics and related facilities and were observed for 10 University School of Medicine, 3. Department of Orthopaedic Sur- or more years of follow-up. The patients were 21 males and 6 fe- gery, Chushin-Matsumoto Hospital males with a mean age of 22.9 years old (range: 17-46). Candi- Gerber’s lift-off test is a valuable method for studying the function dates for surgery were cases with a high degree of shoulder of the subscapularis muscle. Isokinetic muscle tests using a torque Ò instability that caused the shoulder to dislocate easily during daily machine (BIODEX ) reveal the function of inner muscles in the shoul- activities, and cases where a high degree of shoulder stability was der. The purpose of this study was to determine the clinical signifi- required, such as involvement in contact sports. The operation in- cance of Gerber’s lift-off test by using isokinetic muscle tests Ò volved a Bankart repair with a capsular shift, with the addition of (BIODEX ) after surgery to repair traumatic recurrent dislocation a modified Bristow procedure. Patients were cleared to resume daily of the shoulder. We examined 25 cases of traumatic recurrent dislo- activities without restrictions after 4 weeks, and to participate in cation of the shoulder. All the operations were performed under the sports activities after 3 months. A questionnaire survey was con- modified Putti-Platt method (Nobuhara-Hospital method). The cases ducted in order to evaluate the patients’ ranges of motion, JSS shoul- were divided into 2 categories according to Gerber’s lift-off test: der instability scores, satisfaction, rate of recurrent dislocation, and ’’weak’’ and ‘‘normal.’’ Statistically the 2 groups were comparable complications. As X-ray evaluations could not be obtained, the with regard to clinical histories, the Rowe score, and peak torque mean JSS shoulder instability score was 86 on a 90-points scale. Re- per body weight. The operations resulted in 25 ‘‘weak’’ cases be- garding patient satisfaction, 24 patients were completely satisfied, coming 7 ‘‘weak’’ and 18 ‘‘normal’’ cases. There were no significant 3 were somewhat satisfied, and none were dissatisfied or somewhat differences between the 2 categories about clinical histories and the dissatisfied. While no recurrence of shoulder dislocation was ob- Rowe score. The ‘‘weak’’ cases indicated a smaller peak torque per served postoperatively, subluxation was detected in 2 patients body weight in flexion at 180 degree/sec, extention at 60 degree/ each only once. The long-term clinical outcome of the reported pro- sec and 180 degree/sec, in internal rotation at 60 degree/sec (p < cedure was favorable, and it was effective for maintaining long-term 0.05), in external rotation at 60 degree/sec and 180 degree/sec, shoulder stability. and internal rotation at 180 degree/sec (p < 0.01). Dysfuntion of the subscapularis muscle was detected by Gerber’s lift-off test but not by the Rowe score because Rowe score’s sensitivity was lower. ‘‘Weak’’ cases in Gerber’s lift-off test indicated decreased power 135 Quantitative Assessment of the Muscles of the Rotator in almost all the directions. Dysfunction of the subscaplaris muscle Cuff after an open Bankart Procedure for Anterior Dislocation of could cause decreased musclar strength in the shoulder and in these the Shoulder cases patients should refrain from sporting activities and physical la- Nakamichi Noriaki, Matsumura Noboru, Shiono Shohei, Toyama bor. This study concluded that Gerber’s lift-off test was a useful test for Yoshiaki, Ikegami Hiroyasu, Department of Orthopaedic Surgery, high sensitivity and a valuable method for evaluating the function of Keio University the shoulder after operations. e20 Abstracts J Shoulder Elbow Surg

137 Influence of Rehabilitation Density on Clinical Results of + teres minor 0.796, subscapularis 1.231. Though it was unclear Arthroscopic Bankart Repair whether atrophy of the supraspinatus muscle was a cause or a result, Kikugawa Kazuhiko, Department of Orthopaedic Surgery, Mat- this study suggested that there was supraspinatus muscle weakness suyama Red Cross Hospital involved in the impingement syndrome in gymnasts. Muscle strength Mochizuki Yu, Department of Orthopaedic Surgery, Hiroshima Uni- of the supraspinatus was important for both treatment and preven- versity School of Medicine tion of impingement syndrome in gymnasts. Atrophy of the supraspi- Okuhira Nobuyoshi, Adachi Nagao, Department of Orthopaedic natus was significantly more common in patients with an Surgery, Mazda Hospital impingement syndrome. We have performed the arthroscopical Bankart repair for recurrent anterior shoulder dislocation. Rehabilitation after surgery was performed as outpatient or as inpatient. The purpose of this study 146 Clinical Evaluation of Arthroscopic Calcification Removal was to evaluate the clinical results of arthroscopical Bankart repair for Calcifying Tendinitis correlation of the period of hospitalization. We treated 24 recurrent Manaka Tomoya, Ito Yoichi, Nakao Yoshihiro, Naka Yoshifumi, Na- anterior shoulder dislocation by arthroscopical Bankart repair in kamura Nobuyuki, Nakano Motohiro, Tomo Hiroyasu, Matsumoto 2004. The outpatient group was 13 cases and the inpatient group Isshin, Takaoka Kunio, Department of Orthopaedic Surgery, Osaka was 11 cases. Sex, the averaged age at operation, the mean follow City University Graduate School of Medicine up period were not significant in the 2 groups. The clinical evaluation Calcifying tendinitis is classified to 3 phases: acute, subacute was performed using the JSS Shoulder Instability Score. The range of and chronic, according to the severity and the period from the onset motion and muscle strength were evaluated by Cybex. The average of the disease. Conservative treatment is usually effective in acute postoperative JSS Shoulder Instability Score was 92.4 points in the and subacute phases; calcification and symptoms disappear during outpatient group and 93.4 points in the inpatient group. There was the natural course of this disease. However, calcification does not no significant correlation between the postoperative range of motion disappear and chronic shoulder pain remains in chronic phases in and muscle strength in flexion, internal rotation and the period in hos- some cases. Currently a novel technique: arthroscopic calcification pital. The range of motion in external rotation at 2 months after sur- removal was reported in some literature. The aim of this study was to gery and muscle strength in external rotation at 6 months after evaluate the clinical results of arthroscopic calcification removal for surgery in the inpatient group was higher than in the outpatient calcifying tendinitis with a minimum follow-up of 6 months. We ret- group. The clinical results of recurrent anterior shoulder dislocation rospectively evaluated 20 shoulders in 20 patients (10 males and correlated the period in hospital as to the range of motion and muscle 10 females), who were diagnosed as chronic phase calcifying ten- strength in external rotation at an early stage after surgery. dinitis and received arthroscopic calcification removal. The average age at the time of the surgery was 59.8 years old (43 – 83 years old). The average post-surgical follow-up was 20.7 months (7 – 144 A Medical Check of Shoulder Joints of High-school 46 months). We examined calcification and rotator cuff disease Pitchers by the Hara Test with X-ray, 3D-CT and MRI. Clinical results were evaluated using Osawa Toshihisa, Takagishi Kenji, Kobayashi Tsutomu, Yamamoto the JOA scores. Active range of motion of flexion and abduction Atsushi, Suzuki Hideki, Shitara Hitoshi, Shinozaki Tetsuya, Depart- were also evaluated. The average active flexion improved from ment of Orthopaedic Surgery., Gunma University Graduate School 148.5 degrees preoperatively to 159.0 and 167.5 degrees at 3 of Medicine and 6 months follow-up respectively. The average active abduction The purpose of this study was to elucidate the relationship be- improved from 134.5 degrees preoperatively to 151.5 and 160.0 tween shoulder girdle disorders of baseball players and the Hara degrees at 3 and 6 months follow-up respectively. The average JOA test. We investigated 134 pitchers of the Gunma High School Base- score improved from 64.4 points preoperatively to 86.9 and 93.9 ball Association. The check lists were as follows: shoulder pain at the points at 3 and 6 months follow-up respectively. Additional arthro- time of pitching; Hara test (11 items). The correlation between shoul- scopic rotator cuff repair surgeries were performed in 10 cases. der pain at the time of pitching and each check list were examined. We observed a complete calcification removal in 19 of 20 cases Furthermore, evaluation in zeroposition X-rays were examined. 31 (95%) and no recurrence of calcification during the follow-up pe- pitchers had shoulder pain at the time of pitching. The significant re- riod. Patients treated with arthroscopic calcification removal for cal- lations were as follows: SSP test; impingement test; combined ab- cifying tendinitis have showed excellent clinical outcomes at duction test (CAT); elbow extension test (EET); elbow push test a minimum of 6 months follow-up. (EPT); hyper external rotation test (HERT). There was no significant difference between the types of zeroposition X-rays. We thought that the useful check lists were the SSP test, impingement test, CAT, 148 Medication Therapy using Predonisolone for Frozen EET, EPT and HERT. Shoulder (The 2nd report) Takase Katsumi, Kumakura Tsuyoshi, Yoshino Souichi, Shinmura Koutaro, Yamamoto Kengo, Department of Orthopedics, Tokyo 145 Rotator Cuff Muscle Atrophy in Impingement Syndrome Medical University in Gymnasts Since frozen shoulder (adhesive capsulitis) is characterized by Iwaso Hiroshi, Department of Orthopaedic Sports Surgery Kanto- spontaneous recovery, no precise treatment strategy exists. Conser- Rosai Hospital vative therapy is available in the form of physical therapy, and injec- This study investigated the relationship between rotator cuff mus- tion therapy, and joint manipulation, release of the ligaments, and cle atrophy and impingement syndrome in gymnasts.22 male elite arthroscopic surgery are available as surgical therapies, but the gymnasts (44 shoulders) were checked up for shoulder problems time required for recovery varies considerably. Nevertheless, there specially impingement signs. MRI studies were performed for all sub- have been very few reports on medication therapy. In this study jects to measure the cross-sectional area of 3 rotator cuff muscle we found that it was possible to obtain early symptom relief with groups (supraspinatus, infraspinatus + teres minor, subscapularis). oral steroid therapy. The criteria for inclusion in this study were ab- The relationship between the impingement sign and cross sectional sence of osteoarthritic changes or calcification on plain radio- area of the rotator cuff muscle was investigated. 21 shoulders had graphs, absence of rotator cuff injury, including an incomplete a positive for impingement sign. None of the patients showed any rupture, on MR images, and a negative supraspinatus muscle rotator muscle weakness on manual testing. MRI confirmed that (empty-can) test. There were 53 patients (30 males, 23 females), there was no rotator cuff tear in any patient. On the logistic regres- and their ages at the time of treatment ranged from 33 to 67 years sion analysis odd ratios were the supraspinatus 2.330, infraspinatus old (mean: 55.6 years old). Complications consisted of diabetes J Shoulder Elbow Surg Abstracts e21

mellitus in 2 patients, and hypertension in 7 patients. A single course been having dialysis for an average of 18.7 years were operated of steroid therapy consisted of a total dose of 105 mg of prednisolone on. ECLR was performed under local anesthesia in all cases. The fol- over approximately a 3-week period by the dose-tapering method. low-up mean period was 6.7years. We evaluated the results accord- The number of courses varied with the degree of symptom relief, ing to the JOA score and compared them with the ultrasonograpic but the rest period between courses was always approximately 4 changes. We also investigated the recurrent rate and additional op- weeks. The results of treatment were assessed on the basis of the eration. The average JOA improved from 65.3 to 88.7 at 1 month JOA score, but the principal items assessed were pain and range after operation, but became worse at the last follow up (80.6). of motion. The evidence of inflammation of the shoulder joint before The recurrent rate was 17.0%. Additional ECLR was needed in treatment was evaluated by gallium scintigraphy, was noted in 14 of 6cases, open subacromial bursectomy in 2cases, arthriscopic syno- the 17 patients. The ranges of motion before treatment were 102.8 vectomy in 5 cases and arthroplasty in 2cases. ECLR was not effec- of anterior elevation and 11.3 of external rotation, and internal ro- tive in 8 cases. Cervical laminoplasty was required in 3 cases. tation was at the buttocks in almost every case. However, after 1 Although the subacromial lesion is the main cause of the shoulder course of treatment, anterior elevation was 136, external rotation pain in long-term haemodialysis patients, attention to advanced was 33.7, and internal rotation was limited to the buttocks in only shoulder arthropathy, recurrence and cervical lesions must be paid. 6 cases. The results of oral steroid therapy for frozen shoulder (adhesive capsulitis) were highly satisfactory. However, sufficient care was required in explaining the method of administration in case side ef- 152 Amyloid Shoulder Pads: A Case Report fects exist, such as the development of femoral head necrosis. Mikasa Takahiko, Hamada Kazutoshi, Department of Orthopaedic Surgery, Shizuoka Red Cross Hospital Matsumura Noboru, Takahashi Masaaki, Department of Orthopae- 149 Arthroscopic Capsulotomy for Frozen Shoulder dic Surgery, Shizuoka City Shimizu Hospital Evaluation of Rotator Interval Release Yamanaka Kaoru, Yamanaka Orthopaedic Clinic Nakao Yoshihiro, Ito Yoichi, Tomo Hiroyasu, Nakano Motohiro, Na- (Purpose) To report a case of amyloid shoulder pads in the kamura Nobuyuki, Manaka Tomoya, Naka Yoshifumi, Matsumoto course of multiple myeloma. Isshin, Takaoka Kunio, Department of Orthopaedic Surgery, Osaka (Case) A 72 year-old male visited us with a 4-month history of City University Graduate Medical School swelling and pain in the left shoulder joint and both hip joints. The Stiffness is a consistent but nonspecific symptom of primary fro- serum data revealed WBC 6580 /ml, negative CRP, TP6.6 g/dl, zen shoulder. Theories and descriptions of the lesions have varied BUN32.9 mg/dl, Cr3.3 mg/dl, Ca10.3 mEq/L. CT scan showed over time and across authors, with the main target of the pathologi- the lesions of low iso density. MR images showed the lesions of cal condition being reported as the rotator interval (RI). We postu- high intensity on T2-weighted images. Open biopsy and drainage lated the RI was related with the origin of pain. Arthroscopic performed on the both hip joints showed a large amount of yel- capsulotomy has provided promising results in patients with persis- low-white deposit. The culture of the deposit was negative. Patholog- tent stiffness. However, there is little known about the significance ical diagnosis was the necrotic tissue. Postoperatively, Bence-Jones of RI release during arthroscopic capsulotomy. The aim of this study protein was positive and he was diagnosed as a multiple myeloma was to evaluate the significance of RI release in a primary frozen by a bone-marrow biopsy. The specimens taken from the left shoul- shoulder, for pain relief and acquirement of shoulder motion. A pro- der showed amyloid by Congo red staining and the left shoulder spective study was undertaken of 37 patients (24 males and 13 fe- was diagnosed as amyloid arthropathy. males) with frozen shoulder syndrome who were treated with an (Discussion) Huvos et al. reported that the abnormal accumula- arthroscopic capsulotomy including RI release or not. 25 cases tion of amyloid could affect up to 25% of the patients with multiple were treated with RI release (the plus group) and 12 cases were myeloma. Fautrel et al. reported 3% of multiple myeloma cases de- treated without RI release (the minus group). All of the patients veloped amyloid arthropathy. And they reported 91% of the amy- were assessed for pain and range of motion before surgery and loid arthropathy cases were affected in the shoulder joint. A were monitored through to 6-months follow up. Improvement in systemic treatment for multiple myeloma and local treatment were ef- symptoms of shoulder rest pain and night pain were measured by vi- fective. Amyloid arthropathy with multiple myeloma should be con- sual analog scale (VAS) at 3, 7 days and 1, 3, 6 months postopera- sidered, when patients have joint swelling without inflammatory tively. Clinical results were evaluated using the Japanese signs The treatment of amyloid arthropathy could improve the qual- Orthopaedic Association shoulder scoring system (JOA score). A ity of life of patients with multiple myeloma. significant improvement in JOA score was observed in the plus group compared to the minus group at 3 months postoperatively. VAS at rest and at night was significantly decreased in the plus group 153 Tuberculosis of the Shoulder Joints: 2 Case Reports than in the minus group at 7 days postoperatively. This study demon- Nagakura Sakae, Kikuchi Shin-ichi, Shishido Akihiro, Department strated that arthroscopic capsulotomy with RI release was an effec- of Orthopaedic Surgery, Fukushima Medical University tive technique in the management of the frozen shoulder. We reported on 2 cases of tuberculosis of the shoulder. [Case 1] A 76-year-old female who complained of right shoulder pain visited a neighborhood hospital. Since she was diagnosed with rotator cuff 151 Clinical Results of Endoscopic Coraco-Acromial Ligament tear, rotator cuff repair was performed. In the 1-month postoperative Release for Shoulder Pain in Long-term Haemodialysis Patients period, however, wound separation began. With no treatment ef- Nagoshi Mitsuru, Hashizume Hiroyuki, Nagoshi Orthopaedic fects, the patient visited our department 1 year after the surgery. Clinic, Kasaoka Daiichi Hospital The surgery wound was found to have a fistula. X rays and MRIs Shoulder pain induced by dialysis-related amyloidosis is one of showed a destructive change of the shoulder joint. Acid-fast bacillus the most frequent lesions that occur in long-term haemodialysis pa- culture for sputum and exudate exhibited the existence of tubercle tients. We thought that the main cause of shoulder pain was the in- bacillus. She was diagnosed with pulmonary tuberculosis and tuber- crease of subacromial pressure induced by the amyloid deposit in culosis of the shoulder, and administration of antiphthisic was be- the subacromial bursa and rotator cuff, and have performed endo- gun. Then, a lesion curettage was conducted, 5 months after the scopic coraco-acromial ligament release (ECLR) with a view of the administration started. The patient showed no recurrence of this tu- decompression of the subacromial space. We considered pathogen- berculous disorder. [Case 2] An 81-year-old male who complained esis of this lesion by investigating the course after ECLR over 5 years of right shoulder pain visited a neighborhood hospital. He was diag- and comparing them with the preoperative image and clinical find- nosed with periarthritis scapulohumeralis and received conservative ings. 28 men (32 shoulders) and 40 women (56 shoulders) who had treatment. 4 months after the symptoms were found, he showed e22 Abstracts J Shoulder Elbow Surg

fistulation in the axillary region. According to Gaffky using exudate, traumatic episode in group of type II and increased incidence of viewing the results of Gaffkyl, he was diagnosed with tuberculosis of type II in the patients with bursal side tears. ASF was also present the shoulder, and administration of antiphthisic was begun. Lesion in the patients with articular side tears. Degenerative change on curettage was conducted 4 months after the administration was be- the GT was correlated with AHI, severity of cuff degeneration, size gun. The patient showed no recurrence In the above 2 cases of tuber- of tears and age. However, ASF and traumatic episode were not re- culosis of the shoulder, the initial diagnosis was difficult and lated to the change on the GT. Histologic findings of ASF revealed a lengthy period of time was required to confirm symptom appear- the fibrosis with vascular proliferation, sclerotic change of the ance and establish proper diagnosis. Antiphthisic administration bone, and thickening of the fibrocartilage layer due to the mechan- and open surgery prevented further infection. ical stress or reactive bone formation. Degenerative change on the Key words: Ftuberculosis, shoulder joint, infection, GT was associated with severity of cuff degeneration. ASF seems to be the secondary change after a rotator cuff tear since the incidence of a type II and histologic findings. 156 Rotator Cuff Regeneration with Bone Marrow-derived Mesenchymal Stem Cells-Histological and Biomechanical 160 The Long-term Stress Distribution at the Glenoid Cavity Evaluation after a Rotator Cuff Reconstruction using CT Yokoya Shin, Mochizuki Yu, Nagata Yoshihiko, Ochi Mitsuo, De- Osteoabsorptiometry partment of Orthopaedic Surgery, Graduate School of Biomedical Hisada Yukiyoshi, Suenaga Naoki, Oizumi Naomi, Iwasaki Nori- Sciences, Hiroshima University masa, Nagai Masahiro, Minami Akio, Department of Orthopaedic In irreparable rotator cuff repair we usually perform patch graft Surgery, Hokkaido University School of Medicine by using autologous femoral fascia or a polytetrafluoroethylene There have been no reports that have analyzed changes of the sheet. However, these methods have problems regarding sacrifice stress distribution in postoperative glenoid cavity using CTOAM. of normal self-tissue and foreign body reaction. We performed ex- The aim of this study was to investigate change of long-term stress dis- perimental study about the rotator cuff regeneration using mesen- tribution at the subchondral bone of the glenoid cavity after rotator cuff chymal stem cells with a tissue engineering technique. The surgery.Nine shoulders in 8 cases with rotator cuff surgery were inves- infraspinatus tendons of Japanese white rabbits were reconstructed tigated pre- and post-operatively using CT osteoabsorptiometry with poly-lactide caprolactone (PLC) (PLC group), PGA sheet (PGA (CTOAM). The average age of the patients was 66.3 years old group), and PGA sheet with cultured mesenchymal stem cells (range: 45-82). Seven shoulders had anterior acromioplasty with a ro- (MSC group). We sacrificed them at 4, 8 and 16 weeks after oper- tator cuff reconstruction and the remaining 2 shoulders had only ante- ation, and evaluated them histologically with H-E, Safranin O, and rior acromioplasty. The average duration between pre- and post-CT Azan stain and type I and III collagen immunohistochemical stain. examination was 70.6 months (range: 39-90). The measured Houns- And we measured the ultimate mechanical strengths and Young field Unit values at the subchondral bone plate were mapped in 256 moduli of these regenerated tendons at 4 and 16 weeks. In the phases of gray scale using custom-made software. Anterior-superior PLC group, we found massive foreign body reaction around the maximum type was found in 3 glenoids, anterior-superior and poste- PLC fibers, and the arrangement of cells and fibers were irregular rior type in 4 and central maximum with anterior-superior maximum and the cartilage formation in insertion was not found. In the PGA type in 2 before surgery. After surgery, 6 of 7 shoulders which had re- group, PGA fibers were almost absorbed at 16 weeks and regener- ceived rotator cuff reconstruction revealed an increase of stress distri- ated fibrous tissues showed the crimp pattern. In the insertion we bution at the central area of glenoid. The stress distribution at the found the 4 layer cartilage pillar pattern but it mainly consisted of subchondral bone of glenoid cavity in patients without rotator cuff re- type III collagen. In the MSC group, we found the 4 layer cartilage construction had not changed. In a rotator cuff tear shoulder, stress pillar pattern regularly in insertion at 8 weeks and more type I colla- was concentrated on the anterior-superior and posterior-superior gen was found than type III at 16 weeks. The results of mechanical zone by upward deviation of the head of the humerus. After recon- properties show that the regenerated tendons in MSC group had ad- struction of rotator cuff, long-term mechanical stresses were concen- equate ultimate tensile strengths but had low Young’s moduli, that is, trated into the central region and only anterior acromioplasty did are easy to elongate. Therefore, rotator cuff regeneration with bone not lead to an antero-superior stress distribution. marrow derived mesenchymal stem cells had a good capacity of re- generating tendon-bone insertion and producing type I collagen. We thought this method quite useful for regeneration of a rotator cuff defect clinically. 162 A New Suture Technique of Torn Rotator Cuff: A Biomechanical Study Suenaga Naoki, Funakoshi Tadanao, Oizumi Naomi, Hisada Yu- kiyoshi, Mimami Akio, Department of Orthopaedic Surgery, Hok- 159 The Relationship of Acromial Spur Formation, kaido University School of Medicine Degenerative Change on Greater Tuberosity and Sano Hirotaka, Department of Orthopaedic Surgery, Tohoku Univer- Histopathologic Degeneration in Tendons of Rotator Cuff Tears sity School of Medicine Hashimoto Takashi, Inui Hiroaki, Nobuhara Katsuya, Nobuhara Fukuda Kimitaka, Sports Medical Center, Tonan Hospital Hospital and Institute of Biomechanics A high re-rupture rate after the arthroscopic repair of rotator cuff Hamada Tetsuo, Department of Surgical Pathology, Kyushu Rosai with large and massive tear were recently reported on in MRI study. Hospital The objective of this study was to investigate the effectiveness of the The purpose of this study was to determine the correlation of new suture technique biomechanically. 18 bovine infraspinatus ten- acromial spur formation (ASF), degenerative change on the greater dons were repaired to the humerus with 2 suture techniques as fol- tuberosity (GT), and severity of degenerative alteration of the tendon lows: A; a dual-row suture technique with four Fastin anchors and in rotator cuff tears. 100 patients with rotator cuff tears (32 incom- tied by using SMC knot, B; knotless suture of the loop from the medi- plete and 68 complete tears) found surgically were selected to exam- ally placed 2 Fastin anchors with use of 4 bioknotless anchors C, ine the ASF, degenerative change on the GT on plain X-rays and a pull-out transosseous suture of 8 threads from proximally placed correlate these findings with the severity of cuff degeneration. ASF 2 Fastin anchors. The breaking strength, failure mode during tensile was divided into 3 types (type I: no spur, type II: spur formation, testing and the stress distribution immediately after repair of the ro- type III: acromio-clavicular osteoarthrosis). ASF was not related to tator cuff with these techniques using 3 finite element models were severity of cuff degeneration, AHI, LAA, age or duration of symp- compared. The breaking strength was averaged to 310N in A, tom. We observed an increased incidence of complete tears and 283N in B and 368N in B, respectively. Although a stress J Shoulder Elbow Surg Abstracts e23

concentration was seen around the medial anchor in A, no stress was almost normal due to compensation by the scapulothoracic concentration was found inside of the tendon in B or C. A new suture joint, and was little affected by the ‘‘distance of the sutured site.’’ technique could obtain almost the same strength and better stress distribution pattern compared with the dual-row technique. 166 Outcomes of Arthroscopic Treatments for Partial- thickness Rotator Cuff Tears 163 The Effect of Conservative Treatment for Full-Thickness Hashiguchi Hiroshi, Department of Orthopaedic Surgery, Nippon Rotator Cuff Tears Medical School Chiba Hokusoh Hospital Makiuchi Daisuke, Suzuki Kazuhide, Mihara Kenichi, Matsuhisa Ta- Ito Hiromoto, Department of Orthopaedic Surgery, Nippon Medical kayuki, Nishinaka Naoya, Yamaguchi Ken, Tsutsui Hiroaki, Depart- School ment of Orthopaedic Surgery, Showa University Fujigaoka The purpose of this study was to evaluate the outcomes of arthro- Rehabilitation Hospital scopic rotator cuff repair (ARCR) or arthroscopic subacromial de- The aim of this study is to investigate the clinical outcome of con- compression (ASD) and debridement for partial-thickness rotator servative treatment for full-thickness rotator cuff tears (FTRCTs), and cuff tears (PTRCT). The subjects were 62 patients with PTRCT whose to analyze factors that influence the clinical outcome. We selected average age was 54.1 years old. Types of PTRCT were bursal-sided 35 patients who were diagnosed as having FTRCTs by MRI or MR tears (BST) in 40 patients and articular-sided tears (AST) in 22 pa- arthrography and were treated conservatively. There were 19 males tients. According to Ellman’s classification regarding depth of the and 16 females with an average age of 65.3 years old. All patients tears, grade I was observed in 10 patients, grade II was in 36 pa- were evaluated with use of JOA score and were classified into two tients and grade III was in 16 patients. 29 patients (BST: 19 patients, groups; an excellent group with over 80 points and a poor group AST: 10 patients) underwent ASD and debridement, and 33 patients with below 79 points. Comparative assessments of JOA score, (BST: 21 patients, AST: 12 patients) underwent ARCR. The outcomes range of motion, age, sex, dominant versus non-dominant side, trau- were assessed on the basis of the Japanese Orthopaedic Associa- matic history, night pain, the size and location of the cuff tear, and tion (JOA) shoulder score and postoperative MRI findings according duration from the onset to the first consultation were carried out be- to Sugaya’s classification. The average follow-up period was 25.5 tween the two groups. The mean JOA score revealed an overall im- months. The average JOA score in the 62 patients increased from provement from 59.9 at the time of initial examination to 87.2 at the 69 points preoperatively to 93.9 points postoperatively. There last examination. The mean range of active flexion improved from was no significant difference in postoperative JOA scores on the 87.86 at the time of initial examination to 142.86 at the last exam- types of PTRCT. Average JOA score in ASD group improved from ination. In the cases with poor results, pain and ROM score revealed 70.8 points to 93.8 points, and that in ARCR group improved an improvement at one month after treatment, but no significant im- from 67.5 points to 94 points postoperatively. Regarding postoper- provement at the further follow-up examinations. In the several fac- ative MRI findings, the ARCR group obtained type I in 28 patients tors, the size of cuff tear had statistical significance in the clinical and type II in 5, and the ASD group obtained type I in 16 patients, outcome. Our clinical results of the conservative treatments were al- type II in 6, type III in 6 and type V in 1. ASD and ARCR for PTRCT most effective for the patients with FTRCTs. However, our results sug- had satisfactory clinical outcomes. However, postoperative MRI in gested that if the patients reported no or less improvement of JOA patients with grade II or III according to Ellman’s classification score within two or three months after conservative treatment, an op- treated by ASD and debridement revealed insufficient findings erative procedure should be recommended. such as type III and V according to Sugaya’s classification. There- fore, ARCR should be applied to patients with grade II or III according to Ellman’s classification, if possible. 164 Effects on Clinical Results of the Medial Shift of the Repair Site of the Rotator Cuff Hata Yukihiko, Nakamura Koichi, Division of Rehabilitation Medi- 167 Arthroscopic Rotator Cuff Repair without Anchor cine, Shinshu University School of Medicine Ishige Noriyuki, Kuroda Shigehito, Maruta Kimiko, Mikasa Moto- Kobayashi Hirokazu, Department of Orthopaedic Surgery, Chushin- hiko, Matsudo Orthopaedic Hospital Matsumoto Hospital Arthroscopic rotator cuff repair (ARCR) is becoming the 1st Murakami Narumichi, Ishigaki Norio, Itsubo Toshiro, Kubota Su- choice. However, if you use an anchor, the material cost becomes guru, Kato Hiroyuki, Department of Orthopaedic Surgery, Shinshu expensive. The marrow of the greater tubercle (GT) can not be suf- University School of Medicine ficiently exposed to prevent removal of anchors and it is a disadvan- The purpose of this study was to investigate the effects on clinical tage for rotator cuff (RC) healing. We reported our method of results of the medial shift of the repair site of the rotator cuff. The sub- ARCR without anchor. 13 shoulders with a postoperative period jects were 120 shoulders of 120 patients who underwent surgical of more than 6 months were reviewed. The average age was therapy for a rotator cuff tear more than 2 years prior. The distance 61.2 years old. The operation was performed in the lateral decu- from the greater tubercle to the repair site of the rotator cuff was di- bitus position. Arthroscopic acromion plasty was performed. Sev- vided by the diameter of the humeral head on the MRI image, and eral perforated K-wires were inserted per distal of GT into the the corrected value was defined as the ‘‘distance of the sutured optimum part of the foot print. K-wires penetrated the RC and site’’. This value was examined with roentgenographic findings, skin after towing the torn RC to the foot print. No.2 ethibond UCLA scores at 2 years after the operation, and muscle strength. was passed through the RC and GT by pulling out K-wires in the Concerning the distance of the sutured site, significant differences direction of distal of GT again after passing this ethibond into the were seen in muscle strength as an item of the UCLA scores, ability hole of K-wire. Moreover, we made mattress sutures and bridging to elevate to the zero position on an X-ray image 2 years after the sutures after suture relay. The suture was tied on the distal of GT. operation, and muscle strength (p<0.05). It was suggested that The stitch when the thread did not slip was contrived. Active exer- the ‘‘distance of the sutured site’’ was strongly affected by the preop- cise was begun 1 month after operation. In all cases axillary nerve erative rupture size, rather than preoperative adipose degeneration disorder was not seen. The average follow-up period was 9.0 in the fascia of the supraspinatus muscle and changes of arthropa- months. The JOA score was improved from the preoperative aver- thy. The longer rupture size was suggested to result in the risk of age 75.9 points to the postoperative 95.0 points. Although there a postoperative decline in muscle strength. Moreover, long ‘‘dis- were few cases and this report was on short-term postoperative re- tance of the suture site’’ had the possibility of resulting in a disability sults, the result of this method is the same as a conventional to elevate to the zero position. However, the active elevation angle McLaughlin’s method and seemed useful.