FIFTH INTERNATIONALCONFERENCE ON

SURGERY OF THE SHOULDER

July 12-15, 1992Paris, France

Honorary ChairmenJean Debeyre (Paris)

Jacques Duparc (Paris)

ChairmenDidier Patte

Daniel Goutallier (Paris-Creteil)

Organizing CommitteeAndre Apoil (Paris)

Michel Mansat (Toulouse)Gilles Walch (lyon)

Scientific CommitteeBoard of the S.E.C.E.C.Board of the E.S.S.S.E.

S4 Abstracts

MRI OF THE SUPRASPINATUS TENDON: VARIATIONSIN ASYMPTOMATIC INDIVIDUALS Steve A. Petersen,R.G. Holt, Lynne S. Steinbach, Chrlstlan H.Neumann, Wayne State University, Detroit, MI,USA

PURPOSE: To Qescribe the v~riability of MRsignal patterns In the s~Dra~plnatus tendon ofasympto~atlc patlents, allowlng tor MRlcriteria to be establlshed for the definitionof rotator cuff disease.METHODS: 55 Shoulders in 32 asymptomaticvolunteers were evaluated by a 1.5 Teslasupraconductive MR imaging system, utilizing aspecialized shoulder coil, and proton densityand T2-weighted multiplanar images. Imageswere evaluated for tendon signal intensity,location of the musculotendinosis junction andthe appearance of the subacromial-subdeltoidbursae.RESULTS: Increased focal or linearintratendinous signal changes were frequently(89%) demonstrated only on proton density images,with or without loss of the tendon margins. 1hemusculotendinosis junct!on was always locatedwithin 15° medial to 30 lateral, of the twelveo'clock position on the humeral head. Aperibursal fat Rlane was poorly defined in 49%,with subbursal fluid observed 20%.CONCLUSION: Contrary to previous studies,increased intratendinous MR signal on protondensity images, the lack of preservation of abursal fat plane and subbursal fluid are notpredictive of rotator cuff pathology.

2 MRI EVALUATION OF THE cuff abnormalities IN YOUNG PATIENTSWITH SHOULDER INSTABILITYR. Minola *, A. Del Maschio ., A. Vanzulli •* 2A Divisione • Istituto Ortopedico Gaetano Pini - Milano• Servizio di Radiologia- Istituto Scientifico San Raffaele - MilanoMagnetic Resonance Imaging is a sensitive, accurate and notinvasive method for the assessment of both the instabilty problemsand the cuff lesions. We utilized MRI in young patients with shoulderinstability to evaluate preoperatively the incidence of collateralrotatory cuff abnormalities.We examined MR findings of cuff involvement in a series of 21patients ( man age 24 ) with unstable shoulder , compared with acontrol group 0/10 normal stable. On the same we correlatearthroscopic and MR findings during the arthroscopic treatment of theinstability.MRI images of supraspinatus tendon abnormalities were observed in15 of 21 unstable shoulder (71 %) . In the normal control group only 3patients ( 33%) shoved MRI minor abnormalities of supraspinatusbone insertion.At arthroscopy control 18 patients showed detachement of theanterior ligamentous complex with variable degrees of cuff lesionsnot requiring an artroscopic treatment.Minor MR signs of cuff tendinopathy are observable in both thenormal and unstable shoulder but with a clear cut increasedincidence in shoulder instability. Their signilicance seems to becorrelated with aging changes of the tendon both in normal andunstable shoulder and worsened by traumatic strains in unstableshoulder. Diagnostic value of MRI is limited by the overlap of thesame minor signs of tendon aging in some normal patients as inunstable shoulder. The significant frequence of cull MRI imagesabnormalities confirmed arthroscopically , suggest that the cufftendons play an important stabilising role and may be involved in theinstability pathology, but, in our experience, the repair of the mainligamentous damage is the only required treatment.

1. Shoulder Elbow Surg.January/February 7993

3 THE RELATION BETWEEN YRI AND PATIiOLOOICALDIDENERATION OF ROTATOR CUFF. K. Nakagaki. YD,J. Ozaki., Y. Tomita, S. Tamai., D~t of Orth. Surg •Na.ra. Medical UniveIS:i:ty, Kashihan, Nan, JAPAN .

In an advanced degeneration of rotator cuff, thecellularity of the tendon is diminished in general. Westudied the degeneration of torn cuff by canparing tresignal intensi ty of the torn cuff in toRI with the ce,llularity of the tendon. Twenty-seven shoulders of ro­tator cuff tears which were repaired were scanned in0.5 T system on Tl, T2* and proton densi ty-weigJ1tedsequences. The .specimens of torn cuff edge at threeparts were examined microscopically by 400 magnifica­tions and the number of tendon cells in each part _scalculated and averaged. Degeneration of torn cuffwas associated wi th an increase in signal intensity ofthe torn cuff in every image. The signal intensitiesof torn cuffs on T2* and proton density-weighted ima­ges were much more useful for evaluation of degenera­tion of torn cuff rather than T1 ,weigJ1ted image,because it is diffia.ll.t to identify the torn cuff edge inTl-weighted image. The signal intensity of torn cuffshould be compared with that of the deltoid musclerather than wi th that of the supraspinatus muscle onMR images.

4 THE DIGITAL IMAGES WITH COMPUTED RADIOGRAPHY INTHE SHOULDER WITH ROTATOR CUFF TEARY.Tomita.MD. J.Ozaki,MD, & S.Tamai,MD, Dept ofOrthopaedic Surgery, Nara Medical Univ., Japan'

The purpose of this study is to evaluate thediagnostic value of computed radiography(CR)for rotator cuff tear, as compared with conven­tional radiography. The computed radiographs ofboth the shoulder joints with rotator cuff tearin 30 patients and the healthy shoulder jointsin 16 control subjects were reviewed. The dig­tal system used was a FCR-7000(Fuji Photo Film,Tokyo,Japan). The trabeculae of bones such asthe acromioclavicular joint and the subacromialsurface were shown clearly in CR. Especiallyfor soft tissue structures, the enhanced imagewas superior to the conventional image. Al­though the normal subacromial bursa was not vis­ible on routine radiographs, the extrasynovialfat could be identifiable on some enhanced imag­es of normal shoulders. Wetermed this fat layerto be "peribursal fat zone". There was a cer­tain cor~elation between rotator cuff tear anddisappearance of this fat zone on the digitalimage with CR. The overall sensitivity and spe­cificity of the disappearance of peribursal fatzone to the rotator cuff tear was 86% and 77%respectively.

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

5 THE VALUE OF MRI FOR THE DIAGNOSIS OF CUFFTEARS, J.Jerosch, Y.H.M.Castro, J.Assheuer,Westf.Wi Lh.Univ.Munster,Orthop.Dep.

The purpose of this study was to evaLuateMRI in the diagnosis of cuff pathology. We ex­amined 68 patients with SE-(500/20) as weLL asFEDIF-(500/10), and STIR-(1600/100) sequences(surface coiL,l.0 tesla). AIL MRI studies werepreoperativeLy cLassified by the radioLogist(no/partiaL/complete tear) without knowing thepatients' clinicaL findings. In alL cuff tearsthe diameter was documented. At the time ofsurgery the surgeon did not know the resultsof the MRI study. The STIR sequence was thebest of alL sequences. With this sequence onecan almost get an arthrogram effect. Loss ofthe subacromiaL fat line was of no diagnosticvalue. However, a high signal around the bi­ceps tendon seems to be a good secondary signin patients with glenohumeraL pathoLogy. Ofspecial interest were the muscle atrophy inLong standing tears with concomitant fattydegeneration and muscle fibrosis. In partialtears MRI was not reliable. Diagnostic para­meters were: 95% sens., 92% spec., 94% acc.,95% ppv, 92% npv. The preoperative judgementof the size of the tear and the intra­operative findings showed a correlation factorof r=0.93.

6 SONOGRAPHIC EVALUATION OF RECONSTRUCTEDROTATOR CUFF TEARS. U. Brunner, P. Habermeyer,E. Wiedemann, U. Cammerer. Dep. of Surgery, Univ. ofMunich. Nussbaumstr. 20, D - 8 Munich 2, Germany.

For the evaluation of rotator cuff pathology sonography(US) is still uncertain postoperatively. The aim of the studywas to define sonographic criterias following cuff repair andto correlate them to clinical findings. Methods: 110consecutive patients with open surgery for rotator cuffpathology (94% full thickness tears) (46 direct sutures, 33transosseal sutures, 6 cuff transfers, 25 tendon debridements)had a follow up at 21 months ( 4 - 48 m). Evaluation wasdone clinically, isometrically, according to the algofunetionalindex of PATTE and by a 7.5 MHz linear scanner in severalplanes • ~: From 85 shoulders with cuff repair 13(15%) presented a normal US pattern; 21 (24%) tendons wereflattened, 19 (22%) could not be discriminated from thedeltoid muscle, 8 (10%) showed a modified reflex pattern(87%-91 % PATTE). 5 tendons showed an increased and 5 areduced thickness ( 81 %, 78% PATTE). Only 9 shoulderswith no evidence for any tendon structure in the US hadclinically an unfavourable result (59% PATTE) withsignificant difference (p <0,005) to the other groups and anobvious retear of the rotator cuff. Only the size of theprevious tear correlated with the rerupture (>BATEMAN III= 22% rerupture), not the age or the repair-technique.Conclusions: In the US following rotator cuff repair, only themissing tendon structure correlates with a retorn rotator cuff.Most· US criteria distinctive for tears preoperatively persistdespite successful tendon repair.

Abstracts 55

7 THE ROLE OF THE INFRASPINATUS IN ABDUCTIONAND EXTERNAL ROTATION OF THE SHOULDER. 'c.c.Jiang,MD, J.c.Otis,Ph.D, T.L.Wickiewicz, MD,R.F.Warren,MD, 'Nat. Taiwan Univ.Hosp.Taipei, TaiwanROC. The Hosp. for Special Surgery, New York.

The purposes of this study is to quantify thechanges in torque production during abductionand ER of the shoulder which result withparalysis of the infraspinatus muscle.

The dominant shoulders of five male subjectsranging in age from 28 to 33 years were includedin this study. Abduction torque was measuredwith three isokinetic contractions at 45 deg/secwhich were conducted from 0 to 110 degrees ofshoulder abduction prior to and following nerveblock. ER torque was obtained by threeisokinetic efforts at 45 deg/sec which wereconducted from 30 degrees of internal rotationto 45 degrees of ER prior to and following nerveblock. The distal branch of the suprascapularnerve was blocked by injecting 5 to 10 cc of 1%lidocaine in the region where the nerve passesaround the base of the spine of the scapula.Following nerve block the fine wire EMG tracingof the infraspinatus became silent while thesupraspinatus and middle deltoid remained activeboth during abduction and ER. The averageabduction torque reduced 25% to 45% and theaverage external rotation torque reduced 70% to80% after the infraspinatus muscle was paralyzed(p<0.05).

It was concluded that the infraspinatusmuscle is not only a major shoulder externalrotator but also a contributor to the shoulderabduction.

8 THE ISOlATED PARALYSIS OF THEINFRASPINATUS MUSCLE. K. Takagishi, MD, &M. Yamamoto MD, Dept of Orthop. Surg., Sch. ofMed., Kitasato Univ. SAGAMIHARA, JAPAN

Suprascapular nerve entrapment can be caused byvarious pathologic conditions. Of these, a ganglion inthe shoulder region with suprascapular nerve compres­sion is uncommon. Since 1989, six patients werefound to have the isolated paralysis of the infra­spinatus muscle confirmed by EMG studies. All weremale and the age of patients were ranged from 16 to44, averaged 31.7 years. All had atrophy ofinfraspinatus muscle and weakness of external rotationand/or abduction of the involved shoulder. Spaceoccupying lesions in the spinoglenoid notch werefound by ultrasonography and/or MRI in four of them.Physical examination revealed tenderness on thespinoglenoid notch in all with a space occupyinglesion but not in two without it Three of them whounderwent removal of a tumor had immediate painrelief and normal EMG findings were obtained. Thepathology was consistent with a ganglionic cyst. Twowithout a space occupying lesion gradually recoveredconservatively. Isolated paralysis of the infraspinatusmuscle due to ganglia might not be uncommon asthought previously. Furthermore, MRI and ultrasono­graphic scanning can be useful for determining thediagnosis and location of a ganglion causing supra­scapular nerve entrapment, as well as the diagnosis ofa rotator culT tear.

S6 Abstracts

9 INFRASPINATUS SPLITTING INCISION IN POSTERIORSURGERY: AN ANATOMIC AND ELECTROMYOGRAPHIC STUDYBS Shaffer, JE Conway, FW Jobe, RS Kvitne, JETibonei Kerlan-Jobe Orthopaedic Clinic, Inglewood,CA, USA.

A cadaveric and clinical investigation of anew approach to the posterior shoulder was under­taken to assess the efficacy of this method inproviding exposure, preserving tendon attachmentand avoiding muscle or neurologic injury.

This method gained exposure of the posteriorcapsule retractiqgin an interval created bysplitting the infraspinatus tendon in line withits fibers. Posterior shoulder dissection wasperformed on 20 cadaveric shoulders. Four patientswith posterior shoulder instability had a poster:lDrcapsulorrhaphy performed utilizing this newmethod, followed by electrodiagnostic testing.

The infraspinatus muscle was bipennate in allspecimens. The infraspinatus tendon-splittinginterval consistently bisected the posteriorglenoid rim in the mid quadrants, whereas the in­fraspinatus-teres minor interval crossed theglenoid rim in the lower quadrant. Minimalbranching variability was observed in the supra­scapular nerve with either two or three branchesinnervating both pennate bundles. The intervalbetween the posterior glenoid rim and the firstnerve branch crossing the infraspinatus tendon­splitting interval averaged 22.5 millimeters.Clinical EMG and NCV studies of both upper andlower infraspinatus muscle pennate groups showedno evidence of axonal damage or muscle denerva­tion in all four patients.

This study demonstrates that the infraspinatusmuscle is anatomically bipennate and that re­traction between the split pennate bundles maysafely improve exposure of the posterior capsuleand glenoid rim without requiring detachment ofthe infraspinatus muscle tendon.

o INTERNAL ROTATION CONTRACTURE OFTHE SHOULDER. Tom R. Norris, CPMC, SanFrancisco, CA., Jeff Evans, US Navy.

Between 1978 and 1991, 38 patients underwenta subscapularis lengthening to treat significantinternal rotation contractures. There were 19males; 21 females; right side, 22; dominant side,23. The average age was 52 years (range 18 to74). The etiology 01 the internal rotationcontracture was a failed instability repair 16,osteoarthritis 9, traumatic arthritis 9, rheumatoidarthritis 2, other causes 2. Half of the patientswith failed instability repairs had developedcapsulorrhaphy arthropathy with fixed posteriorsubluxation of the head and advanced arthriticchanges. 21 of 38 patients had an average of 2prior surgical procedures (range 1 to 6).Associated diagnoses includeCf osteonecrosis 4,infection 2, prosthesis revision 1, and stiffnessfollowing a rotator cuff repair 1. A 2 cmsubscapularis IenQthening was an isolatedprocedure 7, com6ined with total shoulderreplacement 23, a humeral head replacement 4,arid an inferior capsular shift 4. 36 of 38 patientswere available for followup 12 to 124 months(average 36 months). The pre/postop ER4/46 I elevation 96 {123 degrees. Anaverage of 21 degrees ER were gained with 1cm subscapularislengthening.

J. Shoulder Elbow Surg.January/February 1993

11 MEASUREMENT OF ABDUcrOR STRENGTH USING AN ELEC­TRONICAL DEVICE (ISOBEX). Christian Gerber, M.D.o Arneberg, M.D" Dept of Orthopaedics, Univer­sity of Berne, Switzerland.

Strength measurment is one of the importantparameters of the Constant score. We have tes­ted the strength of abduction in 152 healthyvolunteers using a device allowing a measure­ment of strength over 5 seconds (10 measurementsper second averaged over 5 seconds). The mostregroducible position was patipnt standing, arm90 abducted, arm in plane of scapula, forearmpronated, elbow straight, resistance at thewrist; mean of three measurements was used)the values obtained for normal strength wereage females males

n kg n kg20 - 29 39 4.3(+-0.9) 19 7.9(+-1.8)30 - 39 15 4.7(+-1.0) 21 8.7(+-1.8)40 - 49 12 4.8(+-0.9) 16 10.0(+-1.3)50 - 59 15 4.8(+-1.2) 15 9.4(+-2.2)If the strength was tested at the elbow, thevalues were an average of 190\ of those at thewrist level. Intra and interobserver reliabilitywas good for this group of normal subjects. 75\of individual differed less than 10\ on repeatedmeasurements, means of groups were identical onrepeated testing, no upward or downward trend

12 TIll! ANATCIIY AIID FUIICTIOII OF TIll! CORACO-ACROIIIALLIGAMENT

John E. Harri.Mark C. Blackney

Royal Melbourne Hospital, Melbourne, AustraliaMelbourne University, Melbourne, Australia

Forty coraco-acromial ligamenta in anatomy school cadaverswere dissected with eaphaBis placed upon the subacrOllialextension of the ligament and 1t 1 8 relation to spurforaaUon. The aajor1ty of liguents reached between tenand t .....ty two aUU.-tree bene.th the acrOllian.

Spur fa....tion appeared inti..tely related to the.ubacrOllial .ttachaent of the Uguent and • clearprogr••sion of spur developeent IrOll a fihrocartilagenou8ridge to a large bony .pur .... e.tablished.

It wal 8180 observed that tbe coracoid and acromion arefluihl. structurel and that cOliprelllve and distractiveforces ..ell below e physiological rang. applied betweenth.. resulted in .l.ckening and tightening of the Ugaaent.

Inatron tlsting of scapulae dellOnatratt:d a distractiveforce of only BOlle 30 kilograas produce up to 15al111aetrel of separation of the coracoid and acroaion withaccoapanying tightening of the Uguent and eventualf.Uure .t it '••crllJlial end.

It was therefore proposed that in vivo tension forces austOccur Within the Uqaae.nt wben everyday auscle actIOiiSacra•• the stioulder girdle tend to distract the flexibleacroaion and coracoid. In thi. respect the eoraco-acroaialUgaaent act. as a tension band wi th the traction forcesbeing concentrated at the focal Bubacroaial attaehllent.

This novel tendon band concept occurring over till8 coulduplain the pathogenesis of the observed spur focutions as..ell a. other entitiee, including acrOllial entheBapathyandsupraspinatus outlet narrowing.

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

13 MORPHOLOGICAL VARIATIONS OF THE CORACO·ACROMIAL ARCH AS A POSSIBLE CAUSE OF ROTATORCUFF TEARSF. Gohlke, T. Barthel, J.F. Loehr, A Gandorfer, J. EulertUniversity of Wiirzburg, Department of Orthopaedics, Germany54 cadaver specimens (aged 47-90) were dissected. Aftertransfixation with a polyurethane mould, sections were maode along the coracoacromialligament. The morphology of theacromion was described following the classification of Biglia·ni. Measurements were taken between the long axis of thescapula, the spina and the acromion.

Rotator cuff tears were significantly increased in shoulderswith "curved" acromion, flat acromial slope and, increasedangle between spina and scapula (intact: mean 58°, tears:mean 4]0). In 19 of 20 cases a traction spur was associatedwith rotator cuff tears but incomplete tears completely encasedwithin the ligament.

In contrast to Bigliani we were unable to find a "hooked"acromion. This variation can only be seen in certain x-rayprojections such as "supraspinatus outlet view" but not in theanatomic dissection. The morphology of the subacromial spaceis therefore secondarily determined through the angle betweenthe long axis of the scapula and the spina.

14 THE ASSOCIATION OF AN UNFUSED ACROMIALEPIPIllSIS WITH TEARS OF THE ROTATOR CUFF: AREVIEW OF 41 CASES. I.A. BarralJat,MD, D. BrlItis, MD,E.L. FlDtow, MD, E.B. &if, MD, L. U. BiglUJlIi, MD. TheShoultkr &rvice, New York Orthopaedk HospiJal, Columbia­Presbyterian Medical Center. New York, New York, USA

An unfused acromial epiphisis (UAE), "os acromial", hasbeen associated witb rotator cuff tears & tbe surgical managementof tbis anomaly at tbe time of rotator cuff repair remains unclear.Between 1975 & 1991, we operated on 41 shoulders in 36 patientswitb a UAE, as well as a rotator cuff tear (RC'I). The average agewas 56 years, witb a range of 32-71 years. There were 20 males(55%) & 16 females (45%). There were 8 partial (19%) & 33(81 %) complete cuff tears; 25 supraspinatus tears & 8 massivetears. The average follow-up was 4.5 years, (range: 1-16 years).The axilluy view revealed a mesoacromion in 31 (76 %) &preacromion in 10 (24%). All full tbickness Ref's weremobilized & repaired to bone as needed, & partial tears weredebrided. All preacromions were excised at tbe time of tbeanterior acromioplasty. Management of tbe larger II1CSOlICromionwas more difficult; earlier in tbe series, a fusion was attemptedusing hardware, & 5 were bone grafted. Later, a modifiedacromioplasty was performed witb a burr ratber tban anosteotome, removing only tbe undersurface of tbe protruding bone& leaving a shell of bone in tbe deltoid. There were 22 (54%)excellent or good, 8 (19%) fair results, & II (27%) poor results.In 14 cases, a nH>peration was required: 9 for persistent hardwareproblems, & 8 for a re-tear of tbe rotator cuff. The majority oftbe failures occurred in patients tbat had eitber a fusion or excisionof a mesofragment. A modified anterior acromioplasty witbrotator cuff repair yielded tbe best results.

Abstracts 57

15 ANATOMICAl STUDY FOR THE STABILIZINGMECHANISM OF THE LONG HEAD OF BICEPS BRACHIlINTORN ROTATOR CUFF SHOULDERS. G. sakurai, MD, K.Nakagaki, MD, Y. Nakagawa, MD, Y. Tomita, MD, J. Ozaki, MD,S. Tamai, MD, Dept of Ortopaedic Sorg., Nara Mec!. Univ., NaraJapan.

The purpose of this study is to clarify the instability of bicepslong head in relation to the rotator cuff tear. Rotator cufflesions and bicipital lesions were investigated in 170shoulders of 85 cadavers. Bicipital groove was resected ineach specimen and factors analyzed in evaluating the bicipitalgroove included the medial wall angle (a : angle formed bythe soft tissue, p: osseous wall angle) and the height of themedial wall ( D1 : height of the soft tissue, D2 : height of thelesser tuberosity). The results of measurements at theproximal portion of the groove are listed in table.

No tear IllCOlTQlete tear Complete tear (mean+SPla 43.9±13.f 37.7±12.5" 35.7±15.8"p 29.1±14.8" 25.7±13.0" 26.3±13.1"D1 6.5±1.44mm 6.8±1.82mm 5.1±1.53mm02 25+127mm 26+1530000 21+062mmDecreasing of the mean values for a angle was identified inboth incomplete and complete tear group, but there were notstatistically significant difference in the mean values for pangle. Decreasing of the mean values for D1 was onlyrecognized in the latter group and there were no differences in02 values. It seemed that these changes were caused by thedeterioration of the subscapularis tendon and the coraco­humeral ligament. The medial wall which is the stabilizer of thelong head changes with accompanied by incomplete as well ascomplete cuff tears. And these conditions are apt to incur thesubluxation of the long head.

16 RECOVERY IN RC TEARS PLUS SUBSCAPULARISLESIONS j-l. jUllY, j. lESAOUT, D. KATZ, C. NEROT.

eRF 1l0UARNENEZ, BREST, LORIENT, REIMS.

-We wondered how the patients improved with such lesions.-On the 188 rotator-cuff repairs treated these last threeyears, 23 were associated with subscapularis lesions,(ied 11,1%) .- The assessment was carried out at month 3, 6, and12 with CONSTANT's rating sheet and our functionalshoulder index (FSI). Both checking, pain, motion,function, strength-Whatever was the subscapularis tear association, poorerresults were obtained at the first half year.

- These patients were more painful: 12/30- Total range of active motion score was: 9/20- Function: 43%month 3, 67% month 6, 90% month 12.- Abduction strength: this data was the most impaired,at month 3 with 8% and 24% at month 6.- Global scores were at M3 and M6

28pts and 38pts for CONSTANT's score, 44% and 50%for our F.5.1.Conclusion, Discussion.

Massive tears plus subscapularis got inferior rating withinthe first half year compared to supra+infraspinatus tears.At this period CONSTANT rating is too severe, FSI allows

a closer survey. Nevertheless these$ patients got a pejorativeprognosis

S8 Abstracts

17 RECOVERY BEFORE DELAYED OPERATION FORROTATOR CUFF TEARS J.E. Tomlinson, A.R. Lyons*, K.J.Fairbairn, W.A. Wallace, B.J. Preston. Harlow WoodOrthopaedic Hospital, Nottingham UK.

This retrospective study of 29 patients (9 female, 20 males)reviwed 31 affected shoulders. All patients had been seen previouslywith symptoms severe enough to warrant listing for operation.Because of long waiting lists the operations were delayed for at least12 months. The patients were recalled for clinical re-assessment byan independent surgeon utilising the American Shoulder and ElbowSurgeons Assessment Form with regard to pain, movement, strengthand function. MRI scanning of the shoulder was also carried out.

At review, 39%of patients no longer wished to have surgery, mostlyas their symptoms had improved (Group 1). Seventeen patients with19 shoulders still wanted surgery (Group 2). There was no differencein the ages of males between the two groups. Females in Gp 1 werea decade older that Gp 2. Forty-two percent of Gp 1 and 58 % of Gp2 had the dominant arm affected. At rest, Gp 1 had a lower meanpain score than Gp 2. This difference was more marked when painon movement and at night was assessed. There was no significantdifference in muscle wasting or strength between the groups. Gp 1scored better than Gp 2 for both active movements and passiveexternal rotation. There was no difference with other movements.When functional activities were assessed, the most striking differenceswere in those activities requiring use of the arm above shoulderheight. MRI was unhelpful in identifying which group a patient wouldfall into.

18 TRANSFER OF THE UPPER PORTION OF THESUBSCAPULARIS FOR LARGE AND MASSIVE TEARSOF THE ROTATOR CUFF. E.L. FloJow, MD, C.S. Neer,MD. The Shoulder Semce, New Yori 011ho~dicHospitlll,ColumbiD-Prtsbyterian Mtdical Center, New Yori, New Yori,USA.

Of 274 primary repairs of the rotator cuff performed by thesenior author (CSN II) between 1974 and 1986, 39, in which thetear could not be closed, utilized transfer of the upper portion ofthe subscapularis. There were 28 men and 11 women, with anaverage age of 65 years (range: 47-83). Thirty-{)ne of the 39procedures involved the dominant extremity.

The upper 50-70% of the subscapularis was detached andshifted superiorly, preserving the capsule for stability. Repairswere performed with the arm at the side, but were protected forsix weeks with abduction braces in 31 of the 39 cases.

Thirty-three patients were available for an average of 4.7years' follow-up (range 2-11 years). External rotation averaged72 degrees, and overhead elevation was restored (10) ormaintained (15) in 25 of the 33 cases (76%). Overall, therewere 16 excellent, 9 satisfactory, and 9 unsatisfactory results.The unsatisfactory ratings were generally due to lack of strengthrather than pain, and usually occurred in patients withlongstanding tears with muscle retraction and atrophy.

Transfer of the upper portion of the subscapularis is a goodtechnique for repair of large and massive rotator cuff tears.

J. Shoulder Elbow Surg.January / February 7993

19 ROTATOR CUFF SUBSTITUTES-AN EXPERI-MENTAL INVESTIGATION.R.Kujat,MD,Uelzen,Germany

To evaluate the suitability of rota­tor cuff substitutes,we carried outexperiments using 22 mongrel dogs.Firstwe transected the supraspinatus tendon.6 weeks later ,the reconstruction wasdone using either dacron ligament,carbonligament,mersilene net or a Gore-texpatch.The implants were examined mecha­nical,microangiographically and histo­logically 3,6 or 12 months after recon­struction.The mechanical examination alwaysshowed a layer of loose connectivetissue between tendon and graft,especially in carbon,less in dacron and Gore-tex.The microangiography showed marked dif­ferences in vascularisation of the im­plants,most in dacron and carbon,less inGore-tex.Histologically,all implantsshowed a characteristic pattern of cel­lular infiltration including foreignbody cells and lymphoplasmatic cells,even 12 months after implantation.As a result of these investigations,weare affirmed not to use rotator cuffsubstitutes in humans.

20 REPAIR OF EXTENSIVE ROTATOR CUFF TEARS WITH SYN­THETIC MATERIAL THROUGH A TRABSACROMIOCLAVICULARAPPROACH. H.t~estdagh, r~D, P.Urvoy, MD, E.Butin,r~D, Dept of Orthopaedi c Surgery, Univers ityHospital, F 59037 LilleBetween 1987 and 1990, 22 Dacron prosthesis wereinserted through a transacromioclavicular ap­proach with preservation of a continuous del to­trapezial flap for large tears of the rotatorcuff. The size of the defect reached 3 to 5 cmin 20 cases, more than 5 cm in 2 ; the supraspi­natus alone was involved fn 7 cases (group II) ; in15, at least 2 tendons were torn (group III). Theaverage age of the patients was 61 years.All the patients were reviewed with a mean followup time of 22 months. 10 were satisfied,S happyand 7 deceived with the outcome. Pain improvementwas achieved except after algodystrophy(2), deepinfection (1), rerupture (3) and loosening of theprosthesis (1). Arm elevation improved from 56°to 107°, abduction from 62""to 101° and externalrotation cuff 18° to 25°. Muscle strength wasalways fQund insufficient. The average Constantscore was 50,6/100, better in group II (59,5) thanin group III (46,3). Because the functional outcomeis disappointing and the survivorship of the pros­thesis remains unknown, the procedure should berestricted to large but not massive tears in selec­ted elderly patients who have no history of priorregional infection:

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

21 PROSTHETIC REPLACEMENT IN ROTATOR CUFFDEFICIENT SHOULDERS. L.U. Bigliolll, MD, R.G.PoUock, MD, E.D. Deliz, MD, S.]. McIlveen, MD, E.L.F1Dtow MD. The Shoulthr Service, New York OrthopaedicHospital, Columbia-Presbyterian MediCill Center, New York,New York, USA.

Thirty shoulders in 25 patients with glenohumeralarthritis and rotator cuff deficienllY, who underwent prostheticreplacement were reviewed. The average age at surgery was 67years (range: 36-86 years) with a mean follow-up of 45 months(range: 18-100 months). 19 shoulders underwent humeral headreplacement and 11 had total shoulder replacement. Mobili­zation and reconstruction of the deficiencies in the thin atrophicrotator cuff tissues were attempted in all shoulders. Anteriorand posterior repair was achieved in all; superior coverage wasfully achieved in 15 shoulders and partially in 11. All shouldershad less pain postoperatively, with 93 % achieving satisfactorypain relief. Active foward elevation improved an average of 34°(from 67° to 101°). Total shoulder arthroplasty and humeralhemiarthroplasty provided similar results with respect to painrelief, functional improvement and patient satisfaction. Hemi­arthroplasty shoulders gained significantly more active elevation(+52° vs. +ZO)post-operatively. Cuff repair was easier when ahumeral head prosthesis was used, as there was less lateralizationof the humerus. Also, operative time, anesthesia time and bloodloss were decreased with hemiarthroplasty. Since the lack ofglenoid resurfacing did not adversely affect pain relief orfunction and avoids the potential problem of glenoid loosening,we favor humeral hemiarthroplasty as a treatment forglenohumeral arthritis in the rotator cuff deficient shoulder.

22 TEFLON FELT CUFF PLASTY FOR CHRONIC MASSIVEAND GLOBAL ROTATOR CUFF TEARS -A CURRENTCONCEPT TECHNIQUE AND 5 YEARS' FOLLOW-UP STUDYJ. OZAKI,MD, Y. TOMITA,MD, Y. NAKAGAWA,MD, G.SAKURAI,MD, K. NAKAGAKI,MD & S. TAMAI,MD Dept.of Orthopaedic Surgery, Nara Medical Univ.Kashihara, Nara, JAPAN

The purpose of this stUdy is to describe acurrent concept technique of Teflon Felt CuffPlasty and results of 5 years' follow-up study.To surgically repair chronic massive and globalcuff tears, subacromial decompression and torncuff mobilization must be performed, and thelesion of bicipital long tendon must be evalua­ted. If the torn cuff edge is retracted and alarge defect remains, Teflon Felt Cuff Plastyis indicated. The felt is firmly sutured tothe cuff edge and the edge of the graft mustbe firmly fixed near the tuberosities. If thehumeral head is porotic, it must not injurethe bony tubercles. It is essential thatthere should be some tension on the graft whenthe sutures are tied. In the present study, 51shoulders were able to be followed-up (av. 5.2years) and were evaluated by J.O.A. score.There were minimum complications in all.Forty-six shoulders (90.2%) were graded ex­cellent, 3 shoulders were good and 2 shoulderswere fair.

Abstracts 59

23 CT SCAN EVALUAnON OF MUSCULAR ATROPHYBEFORE AND AFTER REPAIR OF THE ROTATORCUFF. D. Goutailier, J.M. Postel, L. Lavau, J. Bemageau,Dept of Orthopaedic Surgery, H6pitaI Henri Mondor,Cr~teil, France.

The purpose of this study is to evaluate, before andafter surgical treatment, the importance of muscularatrophy in different types of rotator cuff tears and itsfunctionnaI correlations.

63 cases have been studied. All have had a bonyreinsertion of ruptured tendons using eventuallyadvancement techniques of supra and infraspinatusmuscular bodies. Pre-operative muscular trophicity wasgraded in 5 stages by CT scan study of the fattyinfiltration of rotator cuff muscles (grade 0 means nofatty infiltration, grade 4 means that there is more fatthan muscle).

Increase of atrophy with time elapsed between firstsymptoms and operation is quite evident mainly forinfraspinatus, which can degenerate even when its tendonis intact in large antero-superior tears. Beginning atrophyof ruptured infraspinatus is associated with loss of activeexternal rotation. Initially lost external rotation can berecovered after operation when atrophy of infraspinatusis grade 2 (still more muscle than fat) or less. Butinfraspinatus atrophy never regressed even after a goodquality repair (no significative impairment ofsupraspinatus nerve revealed by EMG).

When to decide an operation for rotator cuff tear,surgeon must be aware that muscular atrophy worsenswith time, does not regress after operation, and iscorrelated with impaired function.

24 PROSPECTIVE EVALUATION OF ROTATORCUFF REPAIR. J.Iannotti, MD,PhD, M.Bernot, MD, J. Kuhlman, MD, M. Kelley,PT, Dept of orthopaedic Surgery,university of Pennsylvania, Phila, PA,

Forty consecutive patients havingprimary rotator cuff repair wereprospectively evaluated 2 years aftersurgery and graded by the Constantshoulder score. Scores were normalizedto the opposite shoulder (ifasymptomatic) or to age and gendercontrols. 57% (23/40) tears were largeor massive involving at least 50% of theposterior cuff. 87.5% of cases weregood or excellent (>80/100 points).12.5% of cases were unsatisfactory«70/100 points). Although 87% ofpatients having strenuous or moderatepre-morbid activity level had good orexcellent reSUlts, 60% of them had adecrease in post-operative activitylevel. The results were significantlyaffected (p<0.001) by size of tear,quality of tissue, difficulty of repairand presence of biceps tendon rupture.Post-operative strength and fatigue werealso highly correlated (p<.0.001) withcuff tear size.

S10 Abstracts

25 DELTOlD MUSCULAR FLAP TRANSFER FOR THE TREATMENT OFMASSIVE ROTATOR CUFF TEARS (R.eT.' D.F. Gazielly MD, 13 placede YH6le1 de Ville, 42lXXl St Etienne, FllInce.

Arthro-pneumotomography or MRI was usedfor pre-operative imaging of massive R.CT. Afterspecific pre-operative rehabilitation lasting on average4 months, pain was still moderate or severe, activemobility and strength were poor but full passivemotion had been recovered. Deltoid flap transfer wasperformed in 11 male and 4 female patients with anaverage age of 55. At surgery the tear was found to berestricted to the supraspinatus in 9 cases, the bicepstendon was normal in 3 cases, missing in 1 case anddamaged in 5 cases. In 6 cases the tear involved thesupraspinatus and the infraspinatus with thinning ofthe subscapularis in 2 cases. Surgical techniquecombined deep subacromial depression and transferof an anterior, external deltoid flap sutured to the rimof the residual cuff. 5 cases necessitated tenodesis ofthe biceps tendon. At follow-up averaging 23 months,15 patients had mild or no pain and 73% of patientshad recovered full active mobility after rehabilitationaveraging 8,3 months. Arthro-CT showed degener­ative muscular changes in 4 patients (27%) with poorforward elevation. Results indicate that transfer of agood quality deltoid flap can provide an alternativesurgical approach for the treatment of massive R.CT.

26 TRANSFER OF THE DELTOID MUSCULARFLAP FOR MASSNE DEFECfS OF THEROTATOR CUF : 27 PATIENTS. D,Saragaglia.ACambuzat, Y.Tourne, J,M.Leroy, I.Mardini, M.AbuAl Zahab. C.H,U. Grenoble - HOPltai Sud· France.

Between August 1987 to April 1991, we performed 28deltoid muscular flap for massive defects of the rotatorcuff. This operative procedure has been taken whensimple suture or suture to bone without tension was notpossible, 27 patients were concerned (17 males and 10females) for 28 shoulders involved. The patients werebetween 45 and 69 year of age, at an average of 58.Every time a standard anterior Neer acromioplasty hasbeen done. The results are concerning 25 patients (3people out of see) and were clinically evaluated accor­ding to Constant's score. The average follow-up was20,3 months (from 6 to 40 months). Strengh was equalin 6 patients (24%), reduced in 8 patients (32%), andwrong in 11 patients (44%). Pain relief was in 14 pa­tients (56%); residual pain was (only with effort) in 8patients (32%) but strong with disability in 3 patients(12%). External rotation was normal in 15 patients(60%), internal rotation in 21 patients (84%), flexion in19 patients (76%) and abduction in 16 patients (64%).The muscular deltoid flap transfer according to us is agood operative procedure to repair retracted supraspi­natus or infraspinatus tears as an isolated retractedsubscar.ularis tears. But for the very big rotator cufftears (' bald head"), the functional profits have failed.

1. Shoulder Elbow Surg.January / February 1993

27 REOPERATION FOR FAILED ROTATOR CUFF REPAIRSC. C. Satterlee, MD, Univ. of ill, Kansas City, MOC. S. Neer, MD, Columbia Univ., New York, NY

The purpose of this pape'r is to report a pro­spective study of reoperation after failedattempts to repair tears of the rotator cuff.

72 shoulders in 71 patients were included inthis study. 51 were surgically treated in NewYork and 21 in Missouri. The patients wereclassified into two groups. Group I consistedof patients with a normal deltoid. Group II con­sis ted of patients with a damaged deltoid fromretraction and scarring or denervation.

Group I consisted of 33 shoulders. 28 had re­sidual cuff tears (14 were massive). 29 had re­sidual impingement and all had adhesions. GroupII had 39 shoulders. 29 had residual cuff tears(21 were massive). 27 had residual impingementand all had adhesions. The average age was 59.

Conclusions and Results 1) It is of criticalimportance to accomplish four objectives: a) re­lieve adhesions freeing tendons so they can"pull", b) relieve residual impingement, c) re­pair rotator cuff defects, and d) preserve orrestore the deltoid. 2) Following these princi­ples E or S results were obtained in over 90%of Group I approximating primary repair. 3) Lessthan 57% of Group II obtained an E or S result.Previous deltoid damage was a more importantcause of failure than previously appreciated.

28 tUJ OPERATIVE TRFA'lMFm' OF ACIOfiOCIAVlCULARDISI.a::ATlOO W.Kl.eschpis Ml&R.Reschauer MDAllg.offentl.Krankeohaus LINZ Osterreich

TJ:mImnt eX lC-seraratias is a::nt:mesial.1\JqD:e eX wrI" '\8~ stu¥ is to ElllalIiIE:r.m.iU:s eX p::ina::y rm-q>.lnalJistl All:iItiudfs lee t:D3al:B:lldth ire,cntiinflame­tIxy dI::Lq; cnl P¥Dm1 ee:tises fmn tiE~.lbre­drt:im is:intm:Blq.~ 1l&I'S.In in~ tine c:L 16 nmtiB(5-29} lie ae::1aX T1 p:1tistl46 'll:EBy n,31 T.m clfflSififrl aftR" J7ltiolcgiml a:ilEria(irrlu:lin3 st:IeB 1eltl'llE nuPit;y iKe 1lBl(40 eX 46 cnl29 c:L 31},nem~ is 33 }USS cnl 36 }USS.

Rsilts~ II&IUBl aftB' UIA I'inJllB:' xatin;) salIe,ena::tivt¥ BXXe (laor,midDe,hiljl a::t:ive) cnl X-:I<¥ dllqJs.In 'll:EBy n lie saor 88% g:xrl cnl W!!l.Y g:xrl nBJl.ts(40 c:L 46}R:sJ1t:s ciD:&l:e ldth~ c:L p3t:i£nts cnl a::t:ive ta.e lEttE£'ma1lts(rn bD m:ult :in higl a::t:ive !JDP}In 'll:EBy m lie frurl~ cnl v.g:xrl D:BJlts(29 eX 31}rn~ eX ~, cnl ret:ts:':usilts in a::t:ivepE!l!DB tID.5 {Bt:ifnts 'll:EBy n lHl to re qa:atel ta:ase eX p:s:sis­

tmt {Bin cnl ae c:L 'll:EBy m ta:ase eX asret:ic cg;ar­cne.

10% :in 'It.Esy n SDo1 s1.:igJt: <X' saee calcifiCHtias cnl62% :in T.m,b.tl tlB:e is rn~:inc1:iniml. <1.ItJ:nte in EB:h !JDP-

ItirB:y :fin::t::imal tn:aIJlsll :in tfHIe :injLw::ie; ms ahigl fl.IH5 J:aIe,epOa11y in f(XXt:sIS"~tn:aIJlStlms to p:DI:iIE a W!!l.Y laor arrpl:imt:im mte.

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

29 Alc RESECTION: COMPLICATION IN ACROMIOPLASTYChecchia,S.L.; Doneux,P.S.- Santa Casa HospitalBrazil - Sao Paulo Medical School

We performed 151 open acromioplasties and weresected 44 painful joints. Worse results wereachieved in thse cases. A "DROPPED SHOULDER"occured, with the clavicle protuding into theTrapezius as consequence of damage to the mostimportant "SUSPENSORY" of the shoulder, thatis the superior A/C ligament.

86.3 % of Instability 56.8 % of PainPain simulating residual impingement, which

didn't become negative with the "ImpingementTest", however it did after injection in theposterior border of the clavicle.

We propose a little modification of thetechinique. Only 1 to 1.Scm of the distal cIaviele must be resected with a burr (no damageto the super. Alc lig.), and the coracoacromialligament, then, transfered to the clavicle (asthe Weaver-Dunn procedure). In those patientswhere the ligament has already been resected,and the pain cannot be controlled by physicaltherapy, we can restore the stability by atransfer of a strip from the conjoined tendon.

In conclusion, care must be taken with thesuperior A/c ligament. The transfer of the co­racoacromial ligament to the clavicle helps torestore the lost stability.

SUP. Ale LIG. LESION -. INSTABILITY -. PAIN

30 TENSION BAND FIXATION FOR THE FRACTURE OF THEGREATER TUBEROSITY. K. MATSUI, MD, &K. OGAWA,*MD, Dept. of Orthop. Surg., Saitama MedicalSchool, Saitama., *Dept. of Orthop. Surg.,School of Medicine, Keio Univ., Tokyo.

The purpose of this paper is to describe themethod and to examine the usefulness of tensionband fixation for the fracture of the greatertuberosity which could convert distractive orshearing force into compression.

In the operation, a drill hole is made in thethick diaphyseal cortex and the suture (abraided polyester string) is passed through thishole. Then the suture is placed on the supra­spinatus and infraspinatus tendon close to theirinsertion and is passed through their fullthickness.During the last 5 years, we have performed this

method to 26 patients aged from 21 to 82. Theyincluded 15 patients with 2 part fractures or fx­dislocations, of whom 4 patients were associatedwith minimal displaced surgical neck fxs, and 11patients with 3 part fractures or fx-dislocationsassociated with displaced surgical neckfractures.According to Neer's postoperative evaluation

scale, excellent out come was obtained in 23patients and good in 2 with minimum 6 mosfolIowup. Only one patients was rated as a poor whoindicated non-union of-the surgical neck fracture.Tension band fixation can be used any type of

fracture of the greater tuberosity.

Abstracts 511

31 ASPECTS AND RESULTS OF OPERATIVETREATMENT IN DISPLACED THREE.PARTFRACUTRES OF THE PROXIMAL HUMERUSSchai P., Jockers W., Gachter A.Dept of Orthopedics and Traumatology, Univ.of Basel, CH

Therapeutical management in comminuted humeral headfractures are essentially determined by the number offracture parts. The aim of our study was to present aspectsand results ofoperative treatment of three-part fractures withthe question, whether ORIF could provide an improvementof the functional results compared to conservative methods.From 1985 - 1990 25 displaced three-part fractures of thehumeral head according to Neer's classification were treatedby ORIF, 16 with a so-called minimalosteosynthesis, 9 byadditional plate flXlltion. There was no statistically significantdifference in the Constant-Scores between minimal and platestabilized fractures, reaching a mean value of 86 points(max.l00). Functionally (ADL, glenohumeraIjoint function,strength) a mean score of 64 points (max.75 p.) wasachieved. In 23 % there were radiological signs for a partialhumeral head necrosis, yet without collapse of the headfragment Open reduction and internal flXlltion of three-parthumeral head fractures improves through correct restitutionof the biomechanical conditions the functional result of theglenohumeral joint, especially by preventing from a bonyimpingement. Correct fracture type diagnosis appears in thiscontext of higher importance than the choice of implant usedfor stabilisation regarding humeral head vitality.

32 THE CLINICAL RELEVANCE OF POSTTRAUMATIC AVN OFTHE HUMERAL HEAD. C. Gerber & C. Berberat, Deptof Orthopaedics, University of Berne, Switzer­land.

25 patients with avascular necrosis (avn) ofthe humeral head after orif or crif of a proxi­mal humeral fracture were assessed clinicallyand radiologically after an average of 7.5 ys.

All patients had a significant functional de­ficit with an average Constant score of 45 ptsor 53% of an age- and gender adjusted score.Twelve patients showed malunion (1 of 4 segmentsdisplaced More than lem or 450

), 13 cases were"nondisplaced" after reduction and fixation.Fle.ion averaged 730 in the first and 113

0in

the second group. Abduction was 70 and 106 de­grees respectively, the Constant scores 35 and54 points or 43 and 62% of normal. Well reducedfractures were painful in 38% (slight or mode­rate), malreduced fxs caused pain in 84%. Ifthese data were compared to a series of primaryhemiarthroplasties for comparable fxs, the re­sults were better for hemiarthroplasty than formalreduced avn, but no better than for avn with­out malunion.

CONCLUSION: ORIF or CRIF of proximal humeralfxs which are likely (but not certain) to under­go avn requires anatomical reduction.

512 Abstracts

33 IN VITRO STUDY OF HtJMERAL RETROTORStONBoileau P.•• Walch G.··. M:u.zoleni N.*, Unen l.P"'CHU de Nice. "CHU Lyon·Sud - FRANCE

Radiological and CT scanning methods are c1assicaly used to measure humeralrelIOtorsion in vivo. In order to verify the accuracy of the measures obtained. wemeasured ill \1;"0, the retrotorsion of 6S humerus, from fresh an':J:Iomicspecimens (Crom 67 10 95 years old). with rour dirrerenLS me,hod, :1} a radiological mtlhod using onc rooiogrnph obUlined in the semi-axial view,as discribed by KrOnberg and al.2} a complAl~d lomograPR] method according to a modification of theMukherjee·Sivaya's procedure.3} a computed assisted method, using a Iridimtnlional ,"achin~.

4) a direct melhod. using a torJioflom~ur. after cuuing lhe humeral headsurface.ResulLS are resumed in the table below:

Humeral Radiology cr Scan. Tri.dim. DirectrelrOtorsion (Krtlnberg) Computer method

Average 22·.2 16' 17·.9 17·.2Slandarddeviation 14·.9 13'.3 13·.7 12°.6minimum -17· ·17· ..,'.7 ·5'maximum 55· 44' 47·5 5(J.

The average error of the measures was 6~.3 with the computed tomographymethod and 9°.4 with the radiological method. Among the 65 humerus. 'Necompare the relrotorsion or 28 pairs: the average difference belween the leftand the right humerus was go.S.Conclusions and clinical reve31:1nces :J) The average angle of humeral relIOlorsion (= 18·) is lower than previouslydiscribed in ahe liucralure.2) Humeral relrOlorsion is very variable among the individuals : ~twecn ·6".5and 47·.5.3) Althought cr scan method is more rdiable than radiological mcthod formea.·iiuring humeral relrOlorsion. the :lverage error is very high (6"J and 9°.4).4) RCltOlOrsion is not constant for both humerus of :1 s:Jmc individuaJ (Mo.S).

34 PROSTHETIC PROXIMAL HUMERALREPLACEMENT. D, Sala, MD, L. Aguilella, MD, S.Amillo, MD. Dept of Orthopaedic Surgery andTraumatology. Universitary Clinic of Navarra. Pamplona,Spain.

The multidisciplinary treatment of bone tumorsallows functional conservative surgery withoutcompromising the vital outcome. Adyuvants are animponant factor in the good results today achieved.

This serle is about 10 humeral arthroplasticresections perfonned between 1983 and 1989 in theUniversitary Clinic of Navarra. Four men and 6 womenwith a mean age of 31 years (range: 8 to 63 years). Theethiology was Osteosarcoma in 4 cases, 1 Ewing S., 1malignant schwannoma, 1 malignant fibrous histiocytomaand 3 metasthasic breast carcinoma. Main follow-up 31months. A deltoid-pectoral approach with an anterlor­axternal prolongation was made, the prosthesis appliedeather cemented or not comented and carefull reinsertionof the musculature. Adyuvants (Intraoperative and externalradiotherapy, quimiotherapy) were employded in all cases.

The survival was 40%. One local recurrence in wichamputation was neceesary. The functional result was goodin most of the cases, depending on the amount ofmuscular tissue resected.Conservative surgery in shoulder tumors is a viablealternative to amputation with good aesthetic resuls anddistal function of the upper extremity.

1. Shoulder Elbow Surg.Jonuory/ Februory 1993

35 PRIMARY HUMERAL HEAD REPLACEMENT FORSEVERELY DISPLACED PROXIMAL HUMERUSFRACTURES. G.P. Nicholson, MD, R.A. FIscher, MD, S.l.McIlveen, MD, P.D. McClllln, MD, E.L.FIaIow, MD, L.U.BigUoIIi, MD. 'l1Ie Shoulder Service, New Yon Ort1toptUtlkHospiloJ, CobmtbiD-Prtsbyterlon Medicol Celller, New Yon,New Yon, USA.

Seventy-ooe humeral bead repJacements (HHR) performedin 70 patients for acute 4-part proximal humerus fractures (47cases) or bead splitting fractures (24 cases) were studied. Sixty­five cases (41 women and 24 men with an average of 63 yean;)were available for follow-up at an average of 42 months (range:13-149 months). The average time between injury and surgerywas 14 days. Complications included 2 peri-operative deaths, Ideep infection, 4 tuberosity displacements, and stiffnessrequiring open release in I case. No aseptic loosening wasnoted. There were 27 (42%) excellent, 26 (40%) satisfactory,and 12 (18%) unsatisfactory. The average active elevation was124° (range 20-180°). Two patients (3%) complained ofsignificant pain post-operatively, and 7 patients (11%)complained of ache with weather changes. Of the 12unsatisfactory results, six (SO %) bad documented non­compliance with post-opentive activity restrictions and therapy.Humeral head replacement with tuberosity repair providedsatisfactory results in 82% of patieats with these severe proximalhumerus fractures. Furthermore, 97 % of patients achievedsatisfactory pain relief. The most significant factors associatedwith an unsatisfactory result were lack of patient motivation andpoor cooperation with post-operative therapy protocols.

36 tw..Jl..AA ProSll-ETIC REPlACOOlTS IN ,ACUTE & Q-R(J.lIC CCWLEXFRJICMES OF THE PROXIW\l.. HMRUS. DAVID DINES*, M.D.BRltE MJECKEL, M.D., DAVID ALIDfK, M.D., RUSSELL F.~, M.D., SPOOTS AI{) SIilIUlER SERVICE, 1HE I-DSPITALFffi SPECIAL SURGERY )lID tmlH Sl-mE UNIVERSI1Y I-DSPITAL/CffiNELL lJollVERSI1Y tJEl)ICAL CENTER

ATllXlular stnllder prosthesis has been used in 53coosecutive patients with acute and ChTU1ic carplex traunato the proximal turerus. There \\ere 23 acute fracturedisplacaraTts and 20 patients with IXlst-traunatic arthritisafter fractures.

In the acute gra.(l, the majority had malll1ioo, lUl-lfliooor AVN. In this ~, eight patialts had had previCllSsurgery.

Both ~s coosisted of primarily famles and theaverage age in each graJp was 70 years. FollOtl-l.P was twJyears or rrore in each graJp.

UtilizillJ The I-bspital for Sla:ial Surgery's scoresystan, there \\ere !m 9XXl to excellent results in theacute graJp and 90% 9XXl to excellent results in thechTU1ic~. FOr'tIard elevatioo averaged 117 d:grees inthe acute gra.(l and 114 d:grees in the chTU1ic graJp.Three quarters of patients caJld perfonn ool1Ti1l, activedaily livillJ flflCtioos.

\<I1en all factors \\ere Calsidered, age and tirre tosurgery \\ere clearly siglif icant factors in the acutegraJp, \<tIile age and the need for tl.b2rosityo~ \\ereclinically siglificarTt in the ChTU1ic graJp.

The TllXlular prosthesis systan (Bi01lX1ular SIrolderBiQ'1'Et, Inc., Warsaw, Irdiana) irrproved our results byincreasillJ the ability to tensioo soft tissues, therebyirrprovillJ tuberosity placarent and glerohlJlEral stabi lity.Revisioo surgery was facilitated by the reverse rrorse taperrrodular desigl.

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

37 !UlERAL HEAD Im'IA<»IENl' IN GLmlU£RAL ARIHRITIS.Cofield, R.H., FrankIe, M.A., Rochester, JoIN,Zuckerman, J.D., New York, NY.

Fifty-nine patients with 65 severely painful shooldershad huDeral head replacement withrot insertion of aglenoid canponent for treatment of their glenohuneralarthritis. The diagnoses were rheunatoid arthritis (RA) in30 shoulders and osteoarthritis (Q\) in 35. Follow-upevaluation including Jitysical exanination and radiografbicassessment averaged 8.7 years and toaS always greater than2 years. Postoperatively, severe or intermittently severepain continued in 18 shoulders (28%), 13 with Q\ and 5with RA. Active abduction improved fran a preoperativeaverage of 66° to an average of 108° in RA and fran 100°to 132° in Q\. 'I'lienty-five patients with RA and 27patients with Q\ rated their shoulders as better or lll1ebbetter (80%). Seven shoulders with Q\ and 2 with RA hadsignificant postoperative pain and have tmdergone revisionto a total shoulder arthroplasty (TSA).

Proximal hulleral prosthetic replacement can be successfulin patients with glenohuDeral arthritis; however, painrelief is not as canplete nor as predictable as with TSA.In patients ~ have severe osteoporosis or substantialmedial glenoid erosion and ~e bone will not permitsecure glenoid fixation, huueral head replacement is anacceptable alternative to TSA. In ywnger or lIDre activepatients, the proced1re can be considered, but TSA willusually be the operation of choice.

38 RADIOGRAPHIC ANALYSIS OF 11lE GLENOIDCOMPONENT IN TOTAL SHOULDER ARTHROPLASTYSW O'Driscoll, TW Wright, RH Cofield. Department ofOrthopaedic Surgery, Mayo Clinic, Rochester, MN

A roentgenographic analysis of 81 Neer TSA's implantedbetween 1981 and 1985 was done to define radiographicchanges and their relationships to clinical parameters.Component and interface changes were judgedindependently by three observers. At 4.1 years follow-up (2to 7.8 yrs) lucent zones at the glenoid bone-cement interfacewere complete in 64% and incomplete in 29%. Lucent zonesgreater than or equal to 1 mm were present in 56%. -Theywere complete in 16% and incomplete in 40%. These weresignificantly more common under the flange (83%) than thekeel (47%). outer keel vs. inner tip, and inferior vs. superior(flange and/or keel) (p<O.05). In 21% a lucent line of~ 2mm was seen, but it was complete in only 1 case. A changein glenoid component position • migration and/or tilting ­was present in 13 (16%). Glenoid shift was significantlyincreased by superior humeral subluxation preop or postop.All those with a shift in component position had a lucent lineof~ 1 mm there (100% sensitive @ ~ 1 mm). All those with alucent line of~ 1.5 mm in that zone had glenoid shift (100%specific @ ~ 1.5 mm). The inferior outer keel was thecritical zone for glenoid lucent lines. In this group, onlythree shoulders were revised; a 95% eight-year survivalestimate. However, the radiographic findings cannot beignored.

Abstracts 513

39 9-O..l.fER />RlI-RR.A5TY WIlH 1E..1OID R.PP FCR Q.FF FmN3-TR.ITICN - A. StUIET /'.0, (Rll-{ROE[:nC [FT, St I>NlDThE KlP.,PilRIS, FR<IN:E

Betv.ea1 1~ crd 1991, 17 j:l9tie1ts (11 fElTBles) with ave­r-cg=~ 'IB5 65 ya:rs (53-85) roo a OJff rEpiir with a dll­toid flcp associatEd with a s-culdlr arttrcplasty LSirg aSl.J:,ef"O-lateral~. EtiolO,;jies v.ere OJff trer arttrqa-­t~ in 10 cases, crd failt.re of slu.Jldlr arttrq:>lasty in 3.

With 25 rrmths of follON-lP. 15 j:l9tia1ts ..-.ere j:l9in-freecrd 2 h3ve been re-q:eratEd for persistent j:l9in de to ap:!rSistent p:x:;terior s-culdlr dislocati01 in ene, crd aflcp nocrosis in tre ott-er. R::lSt-q:erative ctx:Lcti01 crdfle<i01 ..-.ere 100" (SO crd 450 p-e-q::». EXterral rotati01 im­p-osEd fran 0 to '2J:P.

n-e p-othesis ..-.ere cx;rg-tJa1t in 11 cases, SlblLD<atEd su­i=S"iosly in 6. A gle-e cx:nplete, rU1 evolutif gle10id liem-­cy VI8S p-ese1t in 10 cases. Ultrascrogr~:tlic evalLati01 oftre del toid flcp has 00En cbN1 in 8 cases.

With this sturt follON-lP, OJff trer reanstru:ti01 witha deltoid flcp associatEd wi th a 9uJldlr arttrq:>lasty rreyCXITJ:flf'E! to arttrcplasties wi th intoct OJff.

40 a-YEAR RESULTS AFl'ER SHOOIDER SYN:JIJEX:':ItMY INRHEllMA'lOID ARI'HRITIS. C. Petersson , MD, & U.Bengner, MD, Dept of Orthopaedics, MalmO GeneralHospital, MalmO, sweden.

17 rheumatoid patients,5 men and 12 wanen, wereevaluated on average a years after open shouldersynovectcmy. 'I'he patients had been 56 years oldon average at operation and their mean durationof RA had been 15 years. 18 operated shoulderswere evaluated clinically with respect to painand function and radiographically according tothe 5-grade Larsen, Dale, Eek systEm.

11 shoulders were rated good, 3 were rated fairand 4 shoulders with persistent pain and dys­function were rated poor. Radiographically 9shoulders were classified into the same grade aspreoperatively, 6 shoulders had deteriorated 1grade and 1 shoulder had impaired 2 grades. 3shoulders rated poor clinically had been classi­fied into grade III and IV preoperatively.Our =nclusion is that shoulder synovectcmy in

painful rheumatoid arthritis is a worthwhileprocedure with lasting results if performedearly in joints with slight arthropathy.

514 Abstracts

41 TOTAL SHOULDER ARTHROPLASTY IN RAS.Fruensgaard MD, P.Helmig MD, P.SuderMD, JO.S0jbjerg MD, Andersen PK MD, O.Sneppen MD.Shoulder-Elbow Clinic, Aarhus UniversityHospital, DENMARK.

PURPOSE: To evaluate long-term results in pati­ents with severe RA who received total shoulderreplacements.MATERIAL: 83 shoulder replacements in 64 patientsMean-age 57 (31-78) years. Follow-up mean 5 yearsRESULTS: 84% had no/slight pain at follow-up.Significant improvement in range of motion wasachieved. Function increased from 12 points pre­op until 27 points post-op. (max.40 points). Noimprovement in strenght was observed. Four gle­noid prosthesis were foud loose, two revised.Significant radiolucency was found in 13 of thehumerus prosthesis and in 20 of the glenoid pros­thesis. None of the prosthesis were found to beloose.In 38% proximal migration of the humeruswas observed.CONCLUSION: Total shoulder replacements in pa­tients with rheumatoid arthritis gives signifi­cant pain-relief, increased motion, improvedfunction and shows a low revision rate.

42 SHOULDER ARTHRODESIS: A FUNCTIONAL OUTCOMEANALYSIS IN FIFTY-SEVEN PATIENTS Robin R. Richards,Dorcas Beaton, James P. Waddell, University of Toronto,Ontario, CANADA.

Fifty-seven consecutive patients who underwentshoulder arthrodesis were reviewed. The techniqueutilized a 10 hole plate secured to the spine of thescapula, bent over the acromion and extended along theshaft of the humerus. The position utilized was 30°abduction, 30° internal rotation and 30° flexion. Forty-sixpatients underwent the procedure for brachial plexuspalsy; 5 patients for "terminal· shoulder instability; 2patients for osteoarthritis; 2 patients for failed totalshoulder arthroplasties and 2 for infection. The patient'sfunction was assessed according to pain, ability toperform activities of daily living, range of motion andpatient satisfaction. Fifty-five shoulders fused within 10°of the desired position. All patients could abduct at least60°, reach their mouth, their ipsilateral front pocket andtheir ipsilateral ear. Patient satisfaction was highest inthose patients undergoing the procedure for brachialplexus injury, osteoarthritis and failed total shoulderarthroplasty. The patients operated on for chronicinstability were not satisfied with the procedure. Patientsatisfaction is highest for paralytic conditions andsituations where other reconstructive procedures havefailed.

J. Shoulder Elbow Surg.January / February 7993

43 BENIGN AND MALIGNANT PRIMARY OSSEOUSNEOPLASMS 01' THE CLAVICLE. J. Callaghan, R.Balk, D. Sweet, A. Alexander. Iowa City, lA,Oakland, CA, and washington, D.C.

Purpose: This paper reviews the benign andmalignant neoplasm of the clavicle evaluatedat the Armed rorces Institute of Pathology.Material. Kethods & Results: All osseousneopla..s recorded a. occurring in theclavicle were evaluated and reviewed. Onlyprimary lesions were included and in all casesdiagnosis, age, sex, region of the clavicle,and the presence of pathological fracture werenoted. Of the 193 ca.es included in our.tudy, there were 44 malignant lesion. and 149benign lesion.. The mo.t common malignantle.ions were Ewing. sarcoma (12), osteosarcoma(8), and lymphoma (6). The mo.t common benignlesions were eosinophilic granuloma (41), bonecyst (23) and giant cell tumor (22). Theaverage age wa. 30 years old (range 3 monthsto 85 year.) and the male to female ratio was2 to 1. The di.tal one-third of the claviclewas the molt common location!.conclu.ion & Significance: Osseou. neoplasm.of the clavicle are not a. uncommon aspreviously documented. When evaluatingpatients for complaints around the clavicleand .houlder girdle, radiograph! should be!crutinized for o••eoU! le.ions.

44 INTERNAL FIXATION VERSUS PROSTHETIC RE-PLACEMENT FOR PROXIMAL HUMERAL FRACTURES.E. Wiedemann, MD, S. Ruchholtz, MD, & P. Habermeyer,MD, City Dept. of Surgery, Univ. of Munich, Germany. .

Purpose: In case of proximal humeral fractures, theresults of surgery depend on the number of fragments,their relative displacement, and the method of reductionand internal fixation used. The influence of these para­meters on the results obtained was studied.

Methods: In a series of 57 patients treated surgicallyfor displaced proximal humeral fractures, 40 could beexamined 31 months after the procedure on an average.They were treated by open reduction and compressionband fixation in 36 cases and plate fixation in 4 cases.

Results: A partial (total) avascular necrosis was foundin 9% (9%) of the 22 fractures involving the surgical neckcompared to 44% (33%) of the 18 fractures involving theanatomical neck. The rates were 0% (17%) in 17 three­part-fractures versus 35% (30%) in 23 four-part-fractures.In 3 of 4 four-part-fractures treated by plate fixation avas­cular necrosis resulted. The Neer rating system indicateda failure predominantly for four-part-fractures (averagerating 55; failure <70; P<0.05).

Conclusions: In case of displaced four-part-fracturesand of those involving the anatomical neck, for the olderpatient prosthetic replacement of the glenohumeral jointshould be considered. For the younger one, the com­pression band technique is superior to plate fixation.

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

45 EVALUATION OF LAXITY OF THE SHOULDER JOINT(FLOATING METHOD) .K.Maruyama, MD, Dept .ofOrthopedic Surg. ,Akiru Municipal General Hosp.,S. Sano, MD, & Y. Yamaguchi,MD,Dept of OrthopedicSurg., Nihon Univ. Sch. of Med.

The method of evaluation of shoulder jointlaxity has not been established yet in spitethat laxity,itself,isthought to be one ofthe major pathologies of shoulder disorders.

We presented a new method of evaluation wi thusing an arthroscopy. (Method) Arthroscopicexamination was done under general anesthesiain lateral position with a traction of theaffected arm.. Saline was injected wi th thepressure of 200 mmHg and the degree offloating of the humeral head away from theglenoid was observed and was classified fromF-O to 4. (Results) Joints having multi­directional instability were rated to be F-3or 4. There was some difference in floatingextent between the group of recurrentdislocation and the group of recurrent subluxa­t i on. Furthermore, there was a tendencythat the looser was the joint, the less intra­articular changes existed among anteriorinstabi I i ty group. The other hand, stiff jointsrevealed F-O or l.(Conclusion) This floatingmethod is relative easy and useful toevaluate joint laxity of the shoulde~

46 Q.INICAL RELEVANCE a= ARTHAOSCOPICALLYOOSERVEDLESIONS IN YOUNG PATIENTS WITH PAINFU. UNSTABLESHCU.DERSM. Randelli, F. Odella, R. Mnola, S. Valentino".2A Dillisione Istitut> Ort>pedico G. Pini - Miano -" PoliclinicoMlitare- Miano

Purpo88 Arthroscopy of young patients wi1h unstable painfulshoulders shows a wide range ofdifferent ligaments and cuffabnormalities. we elCllnined two problems :- tle correlation between clinical and arlhroscopic findings,-1I1e clinical ralevance of main or associated ninor abnormalities1hat can or cannot require a trea1ment .MIIt...1e and M8Ihoda 100 diagnostic and surgical shoulder

arthroscopies of unstable painful shoulders in SUbjects under 42years. Follow up from 6 months to 2 years. Preoperative clinicaldiagnosis: inslability in 32 cases, cuff abnormalities in 24 anddoubtful unstable or painful shoulder in 44 cases.Conelu.ion Painful shoulder in young patients is mostly aninslability pa1l10logy :- instability with different degrees of anterior- inferior IGHLdamage. In 1hese cases pain clinically referred t) the superior­poslerior part of 1I1e shoulder is caused by ninor lesions, slrainor inftammat)ry involvemantof 1I1e superior slabilising mechanismof 1I1e shoulder ,i.e. biceps -labrum complex and pos1ero-superiorcuf!'- painful subluxaling shoulder, progressing into a lrue an1eriorIUlClltion in antera-superior biceps-labrum complex lesions.In our patients ,cuff tears without instability is a rare pa1l101ogy.We support that isolated minor degrees of biceps and cuffinvolvement may cause a painful shoulder in sports, but need aphysi01l1erapic lrea1rnent rather than a surgical one.

Abstracts 515

47 THE ROLE OF DIAGNOSTIC ARTHROSCOPY INRECURRENT INSTABILITY OF THE SHOULDER.J.O.Sl2Jjbjerg,MD, B.M.Madsen,MD & P.Helmig,MD. Shoulder &Elbow Clinic, University Hospital in Aarhus, Denmark.

Aim. To define the value of diagnostic arthroscopy inpatients with recurrent instability of the shoulder.Materials and Methods. Forty-six consecutive patients, 15 fe­males and 31 males, median age 26 years (range 16-47), witha history of shoulder instability were evaluatedclinical,radiological and by arthroscopy.Results. In 32 patients clinical and radiological evaluationclassified the instability as traumatic, recurrent and anterior. Intwo cases arthroscopy revealed a redundant anterior capsulecombined with a Bankart lesion. In 30 cases the arthroscopydid not change the diagnosis nor the planned operation.Fourteen patients had a clinical diagnosis of instability and allhad normal x-rays. Arthroscopy divided this group into 7patients with traumatic, recurrent anterior instability, including3 cases of SLAP lesions. Five had recurrent nontraumaticmulti-directional instabilities, and two were unstable with cufftears.Conclusion. Arthroscopy of the unstable shoulder with clinicaland radiographic signs of anterior instability seems unneces­sary, and should be omitted. However patients with clinicalsigns of instability and normal x-ray findings can be furtherclassified by arthroscopy and the diagnostic specificityimproved.

48 ARTHROSCOPIC CLASSIFICATION OF BANKARTLESIONS BASED ON THE PATTERN OFGLENOHUMERAL LIGAMENT DAMAGE. N. Tsumaki*,M. Yoneda, A. Hirooka, K. Hayashida, * Dept ofOrthopaedic Surgery, Osaka Univ. Med. Sch., Osaka - Japan

Purpose We attempted to classify Bankart lesions intoseveral types arthroscopically, and investigated whether it waspossible to predict the type of lesion by CT arthrographybefore arthroscopy. Methods Arthroscopic evaluation wasperformed in 85 shoulders of 84/195 patients with traumaticanterior shoulder instability who underwent bilateral CTarthrography. Mter defining the Bankart lesion as any typeof glenohumeral ligament dysfunction in addition to labraldetachment (the classic Bankart lesion), we classified theselesions arthroscopically. The discrimination of the five typesof Bankart lesions was analyzed in terms of the CTarthrographic findings of the bilateral shoulder joints usingthe multivariate analysis (the quantification theory ofHayashi). Results Bankart lesions were classified into thefollowing 5 types: Type 1; labral detachment with well ­developed middle and anterior inferior glenohumeralligament (M & AIGHL) (27 cases). Type 2; labraldetachment with poorly - developed M & AIGHL (21 cases).Type 3; ligamentous avulsion with retracted AIGHL (22cases). Type 4; ligamentous disruption with osseous defect (6cases). TypeS; slack AIGHL (9 cases). The accuracy of thediagnosis from CT arthrography was as follows: type I(75.0%), type 2 (73.8%), type 3 (77.4%), type 4 (%.4%),and type 5 (85.7%). Conclusions Bankart lesions can bearthroscopically classified into 5 types based on the locationand severity of the glenohumeral ligament damage, and thesetypes can be distinguished by CT arthrographic findingsprior to arthroscopy.

516 Abstracts

49 ARTHROSCOPIC MANAGEMENTOF RECURRENTANTERIORDISLOCATION OF THE SHOULDER: COMPARISON OF TWOTECHNIQUES AND ANALYSIS OF THE CAUSES OFRECURRENCES. M. Marcacci, R. Buda, S. zaffagnini, A. VlSani,F. Iacono. Istituto Ortopedico Rizzoll • Bologna - ItalyFor four years now we have used the arthroscopic stabilization

techniques for habitual shoulder dislocation, using two differenttechniques: the Johnson's technique, and the Morgan-Gasparimethod. We report the results obtained with the two differenttechniques analysing the causes of recurrence.We refer on 50 cases with a minimum follow-up of 12 months.

The mean age of these patientswas 25.8 years, minimum 17 andmaximum 51. The results were evaluated in accordance with theRowe points card. Stabilization with staples in this group ofpatients was done in 18 cases; suture stabilization in 32.The results are: 38 excellent cases, 7good, none fair and 5 bad.

We observed 5 recurrences, corresponding to the 5 bad cases.The 7 good cases coincided with 2 of the general conflict withthemetal staple edge, 4 with borsltlsat the sutureon the posteriorsurface of the scapula, and 1 case with residual abductionlimitation. One recurrence was observed using staples, and 4recurrences was observed using suture technique.No difference was noted between the two techniques, but both

the recurrences cases complete occurred among the first casesoperated hence whle perfecting the technique. The mainobservation we would make is that the resUts are either verygood or very bad, without In-between gradations. Recurrencesare the resUt of errors of IndlcatJon or of technique

1. Shoulder Elbow Surg.January / February 1993

51 THE X-RAY APPEARANCE OF THE SHOULDER10-23 YEARS AFTER THE EOEN-HYBBINETTEPROCEDURE. M.Wildner,MD, S.Terreri,MO,prof.A.Reichelt,Orth.Abtl.,Univ.Klinikum,Freiburg i.B.(O)

For a clinical and radiologicalevaluation 60 patients could be examined10-23 years after surgery for recurrentshoulder dislocation (bone-blockprocedure). Standard and apical obliqueviews (Garth) and an ap-view of thecontralateral side were used. Glenohumeralosteoarthrosis (OA) was found in 79% ascompared to 14% on the non-operated side(p<O. 001), acromioclavicular OA in 30% vs.18% (p=0.045) . A Hill-Sachs lesion waspresent radiologically in 95%, the boneblock was completely absorbed in 12% andperiarticular ossifications were seen in29%. The radiological degree of OA wascorrelated to both pain (p=0.002) andSUbjective assessment of the outcome(p=0.006). The high incidence ofglenohumeral OA discourages the use ofthis procedure. Provision of data fromnon-bone-block procedures is encouraged.

50 CLINICAL AND RADIOLOGICAL RESULTSOF THE LATARJET-PATTE PROCEDURE

A SERIES OF 594 SHOULDERS(D. DEJOUR, CH. GLORION, B. LEBAYLE, P. THOREUX)

Between 1970 and 1989, five hundred and ninety four Latarjet-Pallecoracoid transfers were performed, in seven French shoulder specialistcentres, for anterior dislocation or subluxation. The aim of this multicentrestudy was twofold:1) To follow the natural history of the coracoid graft (rate or fracture,pseudarthrosis, migration, and lysis) and its arthrogenic effect on the gleno­humeral joint2)To analyse the clinical and sporting results (using Duplay's index) and toestablish any radio-logical findings lIlat correlated willi these results_In the clinical series 01 354 patients, the mean length of follow-up was 59monlll (range 24 monlhs to 19 years). 74% of patients had an excellent orgood resul~ 18% average, and 8% bad. 93% were very satisfied or satisfied.The recooence rate was 1% will all these patients showing a radiographicabnormality (lysis, pseudarthrosis, or fracture of transplant). Instabilitywas more common amongst the throwing athletes (e.g. tennis player). Returnto sports was best in competitive players with the non-dominant armaffected. The type of sport practised clearly influenced the ability to return10 sports. Return to sports correlated statistically with stability, mobilityand loss of pain.In the radiological series, the mean length of follow-up was 38 months.Ostooarlhrosis was present in 5% 01 cases. There was subtotal lysis in 5%,pseudartlvosis in 11%, and fracture in 6% of the grafts. Some operativetechniques increased the ikeliwood of these complications.Correlating the clinical and radiological results has alloVW!d the indications forthe Latarjet-Patte operation to be defined (age, type of sport practised,sporting level, the presence of unfavourable radiological lesions etc...) as VW!IIas the best surgical technique to be used (positioning the graft, itsalignment with subscapularis, and melllod of fixation).

52 HJ!'ERAL RarATIOO OO'IEOIDIY FOR POS1ERIOR SJDJLIERSUBIllXATIOO. R. Peter Welsh, Orthopaedic & ArthriticHospital, Toronto, Canada.Unintentional involuntary JXlsterior dislocation of theshoolder has been successfully treated by a canbinedprocedure incorporating internal rotation osteotauy ofthe lurerus with an anterior inferior capsular shift.Method: 10 indivi<ilals disabled by sympt<ml developing inthe late teens or early 20' s following minor tr8lJIla wereoperated on.Technique: The proximal lureral osteotany used ananterior approach and teclmique similar to that describedby Weber. The distal lunerus was thoogh internallyrotated 25° with regard to the proximal lurerus to red1cehl.lllel"al retroversion preventing the shoolder franslipping posteriorly..tlen placed in fleld.oo-adduction andinternal rotation. The osteotauy was secured withIOOdified semi-bJbular plate and screws and the inferiorand posterior capsular re<imdancy was advanced upm-ds.Results: All osteotanies healed pri.m!lri.ly. Blood supplyto the huneral head was by 1xJne scan unaffected. Therewas an average loss of 25° of external rotation butoverhead r~ was excellent at a mi.ni.Dun of 12 IlIJ[\thsfollOlM.1p.The plate had to be rElllOlTed in 3 cases. Allbut 1 returned to full activity. The sole failure was dueto persistent habitual involuntary dislocation.

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

53 LOCKED POSTERIOR DISLOCATION OF THE SHOULDERChecchia,S.L.; Doneux,P.S.- Santa Casa HospitalBrazil Sao Paulo Medical School

Between May/89 and Dec/9l, we treated 35shoulders ( 32 patients). Surgery were performedin 27 shoulders (26 patients). Follow-up 26m.

Only 3 were acute cases, and 19 had at least1 year of injury. One case, 24 years~

In 2 cases we found no humeral head defects,most had a lesion ~than 20%, and 2 > than 50%.

ll-McLaughlin with very good results.07-Hemiarthroplasy, also good results. In

one case we could not achive stability.OS-Total Shoulder - 2 good, and 3 poor

results. Very difficult to restore thestability without earn joint stiffness.

02-Reconstruction - 1 good, 1 head necrosis.Ol-Arthrodesis - consolidation.Ol-Resection arthroplasty - satisfied.

We could conclude that good results can beobtained if the patient is treated in the firstyear after injury (bettr within 6m.). After 1year the cartilage of the glenoid is alreadydamaged, compelling to Total Shoulder. If theinjury has more than 2 or 3 years, one shouldconsider the arthrodesis or the resection art­hroplasty, mainly if one is not used to thetechnique of Total Shoulder.

54 ROLE OF CAPSULAR srRUCTURES IN INFERIORSHOULDER STABILITY. N. Motzkin, M.D., E. Itoi,M.D., B. F. Morcey, M.D., K. N. An, Ph.D., Mayo Clinic,Biomechanics Laboratory, Rochester, MN 55905 U.S.A.

The purpose of this study was to determine the contributionof the capsuloligamentous (CL) structures to static inferiorshoulder stability. 13 fresh frozen shoulders were cleaned oftissue superficial to the vented joint capsule. The humeralhead center relative to the glenoid center was determined by amagnetic tracking device. 28 static position recordings wereobtained per specimen: A) With and without a 1.5 kg inferiorload, B) with the humerus adducted hanging freely andabducted 90 degrees in neutral rotation, and C) before andafter sectioning the following 6 CL structures. The relativestabilizing effect of the superior CL structures [coracohumeralligament, superior glenohumeral ligament (GHL) and posteriorsuperior capsule] was compared to that of the inferior ones(middle GHL, anterior and posterior bands of the inferiorGHL). In adduction the humeral head migrated inferiorly asthe CL structures were sectioned, but no single CL structureseemed to provide more stability than any other. In abductionwhen the inferior CL structures were sectioned first, thehumeral head migrated inferiorly to a significant degree(p=O.OOO8). When the superior CL structures were sectionedfirst, the humeral head position barely changed (p=O.99).These results indicate that the inferior CL structures are theprimary inferior stabilizers of the abducted shoulder.

Abstracts 517

55 ANTERIOR SHOULDER DISLOCATION IN THEELDERLY. O. Levy, S. Velkes, A. Schindler, F. Lokiec,H. Horoszowski, & M. Pritsch. The shoulder unit, Shebamedical center, Tel-Hashomer, Israel.

Dislocation of the shoulder has been recognizedduring the last decade as a problem in the older agegroup as well as in the young. During the years 1987­1990, 663 patients were treated for shoulderdislocation, at the Sheba Med. Center, of them, 165were patients older than 60 years, which consisted 25%of all dislocations. Of them, 115 had pure anteriordislocation and 29 anterior dislocation with avulsion #of the greater tuberosity. The follow-up period ranged1-5 years. Of the 144 patients 40%(581 were older than80 years. The male/female ratio was 1/3, just theopposite to the known in the young. The majority of thedislocations were subcoracoid-55%(791 followed bysubglenoid-34%(491, and subclavicular-11%(161. Thepercentage of subglenoid & subclavicular dislocationsare significantly higher compared to the incidence seenin the younger age group. 22% had massive cuff tears.15% had # of glenoid, mostly at the inferior rim, and20% had avulsion # of the greater tuberosity. 5%(71 hadnerve injuries, and One patient had vascular injury.11%(161 suffered recurrent dislocations, all weremultiple reccurences. 4 had avulsion of the greatertuberosity, and 6 had massive cuff tears. Theimmobilization time was 2 weeks. All patients regainedpainless functional range of motion while therecurrence rate was higher than expected. In the lightof our findings, we believe that Shoulder Dislocation inthe elderly is of a different nature then in the young.

56 SURGICAL TREATMENT OF FAILEDINSTABILITY REPAIRS. M.T. Glasgow, MD, I.A.Barra11DJ, MD, E.L. F1tJtow, MD, L.U. Bigliani, MD. TheShouJJkr Service, New York OrthoJNUdic HospiJal, Columbia­Presbyterian Medical Center, New Yolf, New Yolf, USA.

Sixty-two patients were evaluated and treated surgicallyafter failed shoulder instability procedures. There were 34 malesand 28 females. The average age was 32 years. Operativeapproach to revision surgery was tailored to the surgicalpathology encountered. Thirty-four shoulders with recurrentinstability (22 with dislocations and 12 with subluxations)underwent reduction of capsular volume with a capsular shiftprocedure, and 14 of these 34 had, in addition, repair ofpersistent Bankart lesions. Fifteen shoulders with osteoarthritisunderwent replacement arthroplasty and soft-tissue balancing.Thirteen shoulders with excessive stiffness due to soft-tissuecontracture underwent open release. Follow-up averaged 22.5months (range 1 year - 8.5 years). Overall, there were 20excellent, 22 good, 8 fair and 12 poor results. Of the 12 poorresults, 8 had persistent instability, and 5 of these 8 had avoluntary component not previously appreciated. Patientsundergoing prosthetic replacement made the greatest gains (80%good or excellent). Failure of prior repair was associated withincomplete correction of all elements of instability, mostcommonly capsular laxity and Bankart lesions. Poor soft tissuebalancing contributed to failure in 13 patients whose primarycomplaint was loss of motion. The results of revision are not asgood as those of primary procedures.

518 Abstracts

57 "OVER THE TOP"Suture Technique for ArthroscopicRepair of S.LA.P. Lesions of the Shoulder.P.Habermeyer,U.Brunner&E.Wiedemann, Dept.of Sur­gery,Klinikum Innenstadt,University of Munich,Germany. The purpose of this study wasto describea new arthroscopic technique for repai r of superiorlabrum lesions. Method: For refixation of the un­stable biceps - labral complex a suture pin is placedanteriorly through the base of the biceps anchor,perforating midways the superior labrum and leavingthe posterior labrum over the post.-sup. edge of theglenoid. The position of this suture pin is characte­rized as "over the top". A second suture pin Is pla­ced below the base of the biceps tendon at theant.-sup. edge of the glenoid perforating the tornlabrum and is drilled through the scapular neck.2 interference knots posteriorly and one knot infront are forming a three point knot fixation stabi­lizing the torn biceps - labrum complex to theglenoid rim in front and back and over the topaccording to a tension band fixation principle.Results: Between 6/90 and 6/91 there have been-treated 16 patients with S.L.A.P. lesions.The followup time was 8 to 21 months. ~o patients were lostfor follow up, there were no intra- or postop.compli­cations. The postop. constant score (max.100) was92 compared to 65 preoperatlvelY,the postop. self­assessment (max.15) was 12.6 compared to 3.9 pre­operatively. Conclusions: The "over the top'" suturetechnique is a safe and secure method for arthros­copic refixation of S.L.A.P. lesions.

58 Shoulder joint in aging paraplegic patients.

Y. ALLIEU M. D.. Ph. BOUSQUET M. D., M. CHAMMAS, M. D..F. OHANNA M.D .. C. PRALLET M.D.

Div. of Hand and Orthopaedic surgerI LapeyronieHospital and Propara center. Montpe lier. France.

In order to evaluate the prevalence and patternof shoulder alterations among paraplegics, 45 pa­tients, paraple~ic for more than 10 years, able totransfer, and Wl thout any history of shoulder traumawere reviewed. 60% of the patients reported chronicpain about the shoulder after an average duration ofparaplegic of 18.8 years. The complaint was bilateralin half of the affected cases. 80% of the affectedpatients showed evidence of impingement sIndrome .X-ray findings appeared to demonstrate a ate andprogressive evolution toward cuff tear arthropathy.There was a correlation between the prevalence ofshoulder pain and above average weight, age at theonset of paraplegia, a high level of daily activityand deambulation with orthosis devices. Decrease ofautonomy as a consequence of shoulder alterations, waslate but could lead the patients to completedependance (5 patients). Thus, because of theoverloading suffered by the shoulder and the rotatorcuff in paraplegics, we recommend early prophylacticmeasures in these patients.

1. Shoulder Elbow Surg.January/February 7993

59 THE RELIABILITY OF THE SUPRASPINATUS-OUTLET-VIEW IN ASSESSING THE ACROMIAL MORPHOLOGY.T. Barthel, F. Gohlke, J.F. Loehr, J. Eulert, A. GandorferUniversity of Wiirzburg, Department of Orthopaedics,Germany

This study compares the anatomic and x-ray appearence ofthe acromion in the supraspinatus-outlet-view, to verify whe­ther the radiographic classification of acromial shapes by Big­liani et al. is reproducible.

54 cadaver shoulder specimen were dissected and the ana­tomic morphology as well as rotator cuffs inspected. X-rays ofthe specimen were taken in the supraspinatus-outlet-view indifferent angles. The results of the anatomic and radiographicmorphology were compared.

In the anatomic dissection a curved acromion was found in46% and a flat form in 54% of the specimen. In radiographicreview a curved acromion was seen in 85% and a flat acromionin 15% of the cases. A hooked form could be found neither inthe anatomic nor in the radiographic study.

When reviewing the morphology of the acromion, we dif­ferentiate between two types: the curved and the flat form.Rotator cuff lesions are more frequently present with the cur­ved type. The flat type often projects itself into a curved sha­pe when reviewd in the supraspinatus-outlet-view. This viewis therefore not considered a reliable tool in judging the acro­mial morphology, the probability of rotator cuff lesions or theresults of subacromial decompression.

60 PRESSURES IN DIFFERENT LOCATIONS OF THESUBACROMIAL SPACE AT DIFFERENT POSITIONS OFTHE HUMERUS

Jalovaara, MD, & Lantto, MD,x Dept. of Surg. and.Lab. of Microelectr.,x Univ. of Oulu, Oulu,Finland.

The purpose of the study was to clarify thatis the pressure directed towards the rotatorcuff by the acromion equal in differentlocations of the subacromial space and is itdependent on the position of the humerus. Thecompressions directed towards rotator cuff bythe acromion were measured in differentlocations of the subacromial space duringdifferent positions of the humerus. Themeasurements were per.cormed under generalanaesthesia during 29 acromioplasty operationsand 8 open repairs of acute a-c-joint using asmall pietzoresistive sensor. The highestcompressions were found under anterolateralpart of the acromion, where they weresignificantly higher in the impingementpatients than in the a-c-joint dislocationpatients. The compressions increased graduallywith the increase of the abduction angle. Therotation of the humerus had a minor effect. Theincreased I pressure zone started at 18-14 mmdistance from the anterior margin of theacromion.

It is concluded that the concentration of thesubacromial pressure under the anterolateraltip of the acromion may play a role in thepathogenesis of impingement syndrome andexplain· the good effect of acromioplasty inthis disease.

61

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

ROTATOR CUFF TEARS ASSOCIATED \IITH ADELTOID PALSY. O.E.Prudnikov, Chair ofGeneral SurGery, Novosibirsk medicalInstitute, Russia.The pur~ose of the study consists in

showing that the classic opinion consi­dering that the deltoid is the primemover of the shoulder is wrong.~e observed 4 cases of isolated axil ­l~r~ pa~sy which had no active mobilityllm~tatlon of the s~oulder. Between1988 and 1992 we operated 22 patientswith rotator cuff ruptures associatedfor 15 times with an isolated axillarypalsy and for 7 times \.,i th an Duchenne­Erb traumatic palsy. The intervention':las performed following to the YJrinci.-:)-les of rotator cuff surgery. - .18 patients have been reexamined \'li th

a 1-4 years follow-up: 12 are excellent,4 good and 2 ~e moderate.

T\.!O results must be underlined: the ac­tive mobi.lity recovery of the arm wasobtain~d about 2 times more rapidly asthe re~nnervation of the deltoid. The re­covery is still possible when the axil­lary palsy is definitive (3 cases).Our experience underlines that the ac­

tive mobility of the shoulder can be ob­tained without the presence of the deltoid

Abstracts S19

63 TREATMENT Of OLD PAINFULL CALCIFIED SHOULDERS BYDECOMPRESSION WITHOUT CALCifiCATIONS REMOVAL. D. GOUTALLIER,F. DUPARC, J.M. POSTEL. Hopital H. MONDOR, CRETElL, FRANCE.The purpose of this study is to show that the reloval of thecalcifications of the rotator cuff is not necessary; anisolated decolpression .ay be efficient.MATERIAL ANO METHODS: 27 patients (23 women, 4.men, meanage 44 years) had been operated on calcifications of thecuff by deco.pression using an antero-inferior acromioplastyand a resection of the coraco-acromial ligalent, through anopen (25) or an endoscopic approach (21. There was no cufftear. The calcifications mainly took place in thesupraspinatus tendon and were strictly left in place in allthe cases. The mean post-operative follow-up about 3 years.RESULTS: The functionnal results were usually obtained after6 months: 19 very good results (no pain, mobility notlimited), 7 good results (no or few pain, mobility not orless li.ited), I poor result (painfull shouluer, mobilityand function 1imi ted). The Constant score a.ont I g patientswas 10 ti.es above gO, under 60 in 2 cases. X-rays showedthe disappearance of the calcifications in 23 patients, 4were persistent but with lower size and density. The 19 MRIshowed that rotator cuff remained continent. with an averagefollow-up 3 years.DISCUSSION: There was no relations between the functionnaloutcome a~the pre-operative type of calcification andsy.ptomatology, the X-ray outcome of the calcifications. Theisolated decolpression seems usefull in order to obtain agood result, carefull to the rotator cuff, able to break theilpigement syndrome wich lay keep on the calcifications.

62 ARTHROSCOPIC SUBACROMIOL DECOMPRESSION: ATWO-YEAR FOLLOW-UP. R.J. Hawkins, MO, S.R.saddemi, MO, J.T. Moor, MD, A. Hawkins, & M.Tew, M.D., The Steadman Hawkins Clinic, 181 W.Meadow Drive, Suite 400, Vail, CO 81657

96 of 112 patients were available forminimum 2-year follow-up who underwent anarthroscopic subacromial decompression in theabsence of rotator cuff tear. There were 59females, 37 males, average age 41.2 years. Thedominant arm was involved in 68\ of cases. 40\of cases were Worker's Compensation patients.All had a minimum one year of shoulder pain andunderwent an appropriate conservative pro9ram.Success was measured by the Neer criter~a aswell as the UCLA score. Forty-six patients(48\1 were rated satisfactory. Twelve of these46 patients (26\1 were Worker's Compensationpat~ents. The UCLA score in this group improvedfrom 14.8 preoperatively to 29.5 post­operatively. Fifty patients (52\1 of the over­all group were graded unsatisfactory. Twenty­six of these fifty patients (52\ 1 were onWorker's compensation. The UCLA score went from15.4 preoperatively to 16.5 post-operatively.Twenty of the fifty failures underwentsubsequent open acromioplasty. Ten of thesepatients obtained appropriate relief. In ourprevious open series w~th a similar patientpopulation and criteria, we had an 87\ satis­factory rate. We were unable to appropriatelycompare our series with other series of arthro­scopic subacromial decompression. We nowperform ·open acromioplasties on Worker'sCompensation patients and use finger palpationthrough the lateral portal at the supposedcompletion of the procedure to insure adequatedecompression if done arthroscopically.

64 EVIDENCE FOR A SUPERIOR GLENOIDIMPINGEMENT UPON THE ROTATOR CUFF. C.M.Jobe, MD,* Dept of Ortho. Surg, The Loma Unda Univ.Med. Ctr., of Loma Linda, Ca., & J. Sidles, PhD, Dept ofOrthopaedics, The Univ. of Washington, Seattle, Wa.

A second site of rotator cuff impingement in addition tothe more common subacromial site was suggested by: 1)Anatomic findings: Ten fresh frozen cadavericglenohumeral joints, without instability, were held inabduction-external rotation and fixed in formaldehyde.After separation in all 10 specimens the tendon of thesupraspinatus bore the imprint of its contact with theglenoid labrum and the labrum had been deformed by thetendon and the greater tuberosity. Two other joints fixedby freezing alone in the abducted-external rotationposition were cut with a band saw. Sections confirmedcontact between the labrum and the undersurface of therotator cuff. 2) Kinesiologic findings: In computer graphicrepresentations of the movement of 8 subjects show thegreater tuberosity approach the articular surface of theglenoid in a fashion that would bring the rotator cuff andglenoid labrum into contact. 3) MRI findings: Twoadditional living subjects, without instability, were studiedin an end range position. Sections showinQ the posterior­superior labrum demonstrate the contact With the greatertuberosity. Discussion: Our findings show contactbetween the rotator cuff and the posterior-superior labrumcan occur. This mechanism would explain featuressometimes encountered in young athletes.

65

66

520 Abstracts

POSTEROSUPERIOR GLENOID IMPINGEMENT ON DIAGNOSTICARTHROSCOPY - G. WALCH M.D., P. BOILEAU M.D., E. NOEL M.D., J.P.

LIOTARD M.D. - From the Centre HospitaJier Lyor>-Sud, Lyon, France

ABSTRACT

Seventeen patients presenting with chronic shoulderpain underwent arthroscopic examination. ~ith the arm pla~ed

in full external rotation and 90· abduction (the throwingposition) impingement was found between the postero-superiorborder of the glenoid and the undersurface of the tendinousinsertions of supra- and infraspinatus. A partial rupture of thecuff, demonstrated by arthrogram, was found in 8 cases,whereas a partial capsulo-tendinous rupture, not demonstratedby arthrogram, was seen in 9 cases. 12 cases had a furtherlesion of the postero-superior labrum.

All but practised a throwing sport. The dominant arm wasinvolved except in a body-builder. Their mean age was 25years (range 15to 30 years) with symptoms present for a me,,:"of 27 months. None had clinical, radiological, nor arthroscopIcevidence of anterior instability.

Pre-operative clinical examination typically revealedlocalised pain on full external rotation and 90· abduction, withsigns of rupture of the rotator cuff ; impingement sign positive,and pain and weakness on testing supraspin~tus. In 10 cases,CT arthrogram showed evidence of abnormality at the postenoredge of the glenoid. The mean humeral retrotorsion was 10·(range O· to 28").

THB SHOULDER IMPINGEMENT SYNDROME: MANAGEMENTOF TREATMENT FAILURES. Charles A. ROCkwood, Jr.,MD, Gerald R. Williams, MD, University of TexasHealth Science Center, San Antonio, Texas, USA.

From Kay 1978 through June 1988, 117 patients(118 shoulders) were referred to the seniorauthor because of continued shoulder painfollowing surgery for impingement syndrome.Treatment of failures fell into three categories:

Group I - (20 patients). Incorrect diagnosisof the impingement syndrome: idiopathicglenohumeral arthritis, 13 patients; glenohumeralinstability, 5 patients; loss of origin ofanterior deltoid to acromion, 3 patients.

Group II (11 patients). Complicationsfollowing the impingement operation: infection, 3patients; loss of axillary nerve to anteriordeltoid, 5 patients; loss of origin of anteriordeltoid to acromion, 3 patients.

Group III - (90 patients). Persistent symptomsof impingement following the impingementprocedure: responded to specific rehabilitationprogram, 32 patients; failed the rehabilitationprogram and underwent a revision acromioplasty,58 patients.

At the time of revision acromioplasty, themost common and consistent cause of symptoms wasthe prominence of the anterior acromion whiche~tended beyond the anterior border of theclavicle. During passive flexion of the arm, theprominent anterior acromion persisted to impingeinto the subacromial bursae and rotator cuff.After the removal of the anterior prominence ofthe acromion and smoothing of the anteriorinferior corner of the acromion, the arm could be

conf'd

J. Shoulder Elbow Surg.January/February 7993

conf'dpassively flexed without further impingement.

Patients were followed for an average of 3.5years (range 2.3-10.3 years). One patient diedduring follow-up. Results were 42% excellent, 26%good, 18% fair, and 14% poor. We conclude thatthe failures of management of patients withimpingement syndrome of the shoulder result frommisdiagnosis, complications of surgery, andresidual impingement secondary to residualanterior acromion following the traditionalacromioplasty.

We emphasize that to avoid persistent symptomsof impingement following the acromioplastyprocedure, care should be taken to remove notonly the prominent inferior acromion but also anyprominent anterior acromion that extends beyondthe anterior border of the clavicle.