Sunao Fukushima

TRANSFER OF LATISSIMUS DORSI FOR IRREPARABLE ROTATOR-CUFF TEARS

We treated 12 shoulders in ten patients with irreparable rotator-cuff tears by transfer of the latissimus dorsi. There were nine men and one woman. Their average age was 64.0 years and the average follow-up was 35.6 months (26 to 42). The results were excellent in four shoulders, good in four, fair in one, and poor in three. Active forward flexion improved from a preoperative average of 99 degrees to a postoperative average of 135 degrees. Osteoarthritic changes appeared in five shoulders and proximal migration of the humeral head progressed in six. EMG revealed that nine of the 12 transferred muscles showed activity which was synergistic with the supraspinatus on external rotation with abduction. We conclude that latissimus dorsi transfer can be effective in restoring shoulder function after massive irreparable tears of the rotator cuff.

Arthroscopic Bankart Suture Repair for Traumatic Anterior Shoulder Instability: Analysis of the Causes of a Recurrence

Eighty-two patients with traumatic anterior shoulder instability were treated with an arthroscopic transglenoid multiple suture technique (Casparis method) and followed-up for more than 2 years. A retrospective analysis of the clinical outcome was performed to determine the factors related to poor results. The mean age at operation was 21 years (range, 13 to 50 years) and the mean follow-up period was 40 months (range, 24 to 70 months). According to the status of the ligament-labrum complex and the glenoid bone defect, the Bankart lesions were classified into five types arthroscopically. There were 21 shoulders of type 1, 33 shoulders of type 2, 22 shoulders of type 3, and 6 shoulders of type 5. Twenty-four of the patients played contact sports before the operation. The clinical outcome was assessed by Rowes criteria (1978). To analyze the factors related to a poor outcome, a multivariate analysis was done to assess the influence of 12 clinical factors (age at operation, age at first dislocation, sex, dominant side, disease duration, number of dislocations, sporting activity before operation, inferior joint laxity, thickness of the ligament-labrum complex, type of Bankart lesion, number of sutures, and method of suture fixation). Fifty-five of 82 patients had an excellent outcome, 14 had a good result, and 13 had a poor result. According to postoperative instability, redislocation was seen in 13 patients (16%), resubluxation in 2 patients (2%), with a recurrence rate of 18%. The mean limitation of external rotation at 90 degrees abduction was 6.0 degrees (range, 0 degrees to 30 degrees), and there was a 10 degrees loss of external rotation in 10 patients. The factors significantly related to recurrence were a type 3 Bankart lesion, playing contact sports preoperatively, a thin ligament-labrum complex, and repair with less than four sutures. In conclusion, a 18% rate of recurrence is not acceptable. To obtain a better clinical outcome, very careful selection of patients for this technique is necessary. Our analysis of the factors related to a poor outcome may help to decide what the proper indications are for this technique.

Reconstruction of a defect of the rotator cuff with polytetrafluoroethylene felt graft: RECOVERY OF TENSILE STRENGTH AND HISTOCOMPATIBILITY IN AN ANIMAL MODEL

We reconstructed defects in the infraspinatus tendon u sing polytetrafluoroethylene (PTFE) felt grafts in 31 beagle dogs and examined the mechanical responses and histocompatibility. Except for one infected specimen, all the reconstructed infraspinatus tendons healed. We examined eight specimens each immediately after surgery and at six and 12 weeks. The ultimate tensile strength of the reconstructed tendons was 60.84 N, 172.88 N, and 306.51 N immediately after surgery and at six and 12 weeks, respectively. The stiffness of the specimens at the PTFE felt-bone interface was 9.61 kN/m, 64.67 kN/m, and 135.09 kN/m immediately after surgery and at six and 12 weeks, respectively. Six tendons were examined histologically at three, six, 12 and 24 weeks. Histological analysis showed that there was ingrowth of fibrous tissue between the PTFE fibres. Foreign-body reactionswere found at the margin of the PTFE-bone interface between 12 and 24 weeks. The mechanical recovery and tissue affinity of PTFE felt to bone and to tendon support its use for reconstruction of the rotator cuff. The possible development of a foreign-body reaction should be borne in mind.

Bankart Procedure Augmented by Coracoid Transfer for Contact Athletes with Traumatic Anterior Shoulder Instability

We investigated the clinical efficacy of the Bankart procedure augmented by coracoid transfer for traumatic anterior shoulder instability in athletes playing contact sports. Eighty-three athletes (85 joints) with traumatic anterior shoulder instability who underwent the combined procedure were studied. The mean patient age at surgery was 21 years, and the mean follow-up period was 5.8 years (range, 2 to 12). According to the Rowe scoring system, the clinical results were graded as excellent for 58 shoulders, good for 21, fair for 5, and poor for 1, with an average score of 91 points. The overall success rate was 93%. A complete return to contact sports was achieved by 73 of the 83 patients (88%). The average loss of external rotation was 15° with the arm at the side and 7° with the arm in 90° of abduction. The complications were nonunions in two cases, screw breakage in one case, and axillary nerve injury in one. This procedure can achieve a good clinical outcome for contact athletes with traumatic anterior shoulder instability.

Reconstruction of a defect of the rotator cuff with polytetrafluoroethylene felt graft

We reconstructed defects in the infraspinatus tendon u sing polytetrafluoroethylene (PTFE) felt grafts in 31 beagle dogs and examined the mechanical responses and histocompatibility. Except for one infected specimen, all the reconstructed infraspinatus tendons healed. We examined eight specimens each immediately after surgery and at six and 12 weeks. The ultimate tensile strength of the reconstructed tendons was 60.84 N, 172.88 N, and 306.51 N immediately after surgery and at six and 12 weeks, respectively. The stiffness of the specimens at the PTFE felt-bone interface was 9.61 kN/m, 64.67 kN/m, and 135.09 kN/m immediately after surgery and at six and 12 weeks, respectively. Six tendons were examined histologically at three, six, 12 and 24 weeks. Histological analysis showed that there was ingrowth of fibrous tissue between the PTFE fibres. Foreign-body reactionswere found at the margin of the PTFE-bone interface between 12 and 24 weeks. The mechanical recovery and tissue affinity of PTFE felt to bone and to tendon support its use for reconstruction of the rotator cuff. The possible development of a foreign-body reaction should be borne in mind.

Ender nailing for unstable surgical neck fractures of the humerus in elderly patients.

The purpose of this study was to assess the effects of stabilization of displaced and unstable surgical neck fractures of the humerus by Ender nailing followed by protected passive range of motion exercise of the shoulder. Thirty-four patients (29 women and 5 men) with such fractures were treated. The average age of patients was 69.5 years (range, 48-86 years), and the average followup period was 9.9 months (range, 6-22 months). Protected passive range of motion of the shoulder was started in 2 weeks after surgery for 25 patients and in 3 to 4 weeks for 9 patients. All patients experienced pain relief immediately after surgery. Bone union occurred at 5.9 weeks (range, 4-10 weeks) in all but 1 patient. The average range of motion of the shoulder at followup was 129.7 ° elevation and 43.2 ° external rotation. The average limitation of elbow extension was 4.3 °. The most important points of this procedure are to obtain immediate relief of pain, to stabilize the unstable fragment, and to begin protected passive range of motion of the shoulder before extensive adhesions develop.

Arthroscopic removal of symptomatic Bennett lesions in the shoulders of baseball players: arthroscopic Bennett-plasty.

Background: Bennett lesions are often observed in throwing athletes, and, although usually asymptomatic, they can sometimes become painful and disturb an athletes throwing ability. Because it is clinically difficult to determine whether a Bennett lesion is symptomatic or whether pain is from another lesion, the outcome of surgical treatment is variable. Hypothesis: Arthroscopic resection of Bennett lesions diagnosed according to our criteria and arthroscopic treatment of associated lesions performed simultaneously were effective for treatment of baseball players with symptomatic Bennett lesions. Study Design: Prospective cohort study. Methods: The following criteria for diagnosis of a symptomatic Bennett lesion were used to identify 16 baseball players who later underwent arthroscopic removal of the symptomatic Bennett lesion (arthroscopic Bennett-plasty): 1) detection of a bony spur at the posterior glenoid rim on radiographs; 2) posterior shoulder pain during throwing, especially in the follow-through phase; 3) tenderness at the posteroinferior aspect of the glenohumeral joint; and 4) relief of pain by injection of local anesthesia. Results: After a minimum follow-up of 1 year, there was no tenderness at the posteroinferior aspect of the glenohumeral joint in any of the patients. Throwing pain disappeared in 10 shoulders and was mitigated in 6 shoulders. Eleven patients returned to baseball at their previous level of competition. Conclusions: Accurate diagnosis and minimally invasive arthroscopic surgery are important for appropriate treatment of baseball players with symptomatic Bennett lesions.

Mechanical strength of latissimus dorsi tendon transfer with Teflon felt augmentation

Tensile properties of Teflon felt augmentation after latissimus dorsi tendon transfer to rotator cuff defect were examined in dog cadaver shoulders. Two experimental groups with latissimus dorsi tendon transfer were designed. In group 1 (right shoulders, n = 7) the tendon ends of latissimus dorsi were sutured to the greater tuberosity. In group 2 (left shoulders, n = 7) the repair was augmented with Teflon felt at the suture site. The ultimate tensile force and stiffness of each specimen in group 2 were individually compared with those in group 1. The average increases in ultimate tensile force and stiffness in group 2 were 53.8% and -3.7%, respectively. The individual value of ultimate tensile force in group 2 was significantly greater than that in group 1. These results demonstrate that augmentation at the repair site is mechanically effective latissimus dorsi tendon transfer. The augmentation procedure may provide protection during the healing period because of this and a surrounding fibrous tissue reaction.