Title:
[Arthroscopic findings concerning rotator cuff lesions and their operative management].

Abstract:
Our objective is to introduce our simplified, easy-to-use classification of rotator cuff (RC) lesions, describe the frequency of individual findings in a considerably large series of shoulder joints examined by arthroscopy, evaluate the results of the operative management of individual lesion types, and recommend optimal surgical approaches.
Over the course of 10 years (between October 1st, 2000 and December 31st, 2009), 756 arthroscopic operations on the shoulder joint were performed. RC lesions were identified in 516 cases. We categorized the lesions using our own classification. Patient characteristics were as follows: the mean age was 43 years, 69% of the patients were men, and the right shoulder was affected in 61% of the cases (with the dominant upper limb being affected in 71% of the cases). The patients were followed up for a minimum period of 6 months.
All operations were performed in the "beach-chair" position under general anesthesia or in an interscalenic block. The arthroscope was introduced into the shoulder joint through the "soft-spot". Continuous lavage via an arthroscopic pump was used. The glenohumeral joint was examined first; an examination of the subacromial space followed. Once the lesion type was identified, other procedures were performed. In standard situations, type I lesions were managed with ASK sub- acromial decompression (SAD). As to type II lesions, we initially performed open RC reconstruction with acromioplasty, which we later replaced with ASK-assisted RC reconstruction with SAD; we are currently managing these lesions with ASK RC reconstruction + SAD. As for type III lesions, we initially used to treat them with open RC reconstruction with acromio - plasty; we are now performing ASK-assisted RC reconstruction with mini-incision + SAD. We are trying to use "double-row" sutures in certain cases. The initial management of type IV lesions consisted of ASK palliative resection of RC remnants combined with SAD. Currently, we are performing partial muscle transfer of the intact subscapularis muscle tendon (Karas) or partial non-anatomical RC reconstruction (Burkhart). A combination of both methods described above was required in some cases. If delamination of the RC was found, partial reconstruction using the "double-layer" technique took place. Open acromioplasty was added during all operations. Type V lesions are managed with ASK palliative resection of RC remnants + SAD; when this approach proves unsuccessful, which is a rare phenomenon, resurfacing follows. The results were evaluated after 6 months using a modified Constant functional score. Besides clinical examination, self-assessment questionnaires filled in by the patients were also evaluated.
Out of a total of 516 RC lesions, type I was the most prevalent (54%), followed by type V (16%). The prevalence of lesion types II, III and IV was about 10% each. In type I, the mean improvement measured by the Constant score was 36 points. As for type II, open reconstruction, ASK-assisted reconstruction and ASK reconstruction resulted in mean improvements of 31, 34, and 35 points, respectively. While open reconstruction of type III lesions was associated with a 27-point improvement on the Constant score, the use of ASK-assisted reconstruction resulted in a 29-point improvement. In type IV, the use of ASK palliative resection of RC remnants, muscle transfer (Karas), partial reconstruction (Burkhart), and a combination of the last two methods led to the mean 19-, 25-, 22-, and 22- point improvements respectively. Following ASK palliative resection, the mean Constant score improvement in type V lesions was 17 points, while the use of resurfacing, if performed, was associated with a 21-point improvement. DISCUSSION In type I lesions, favourable long-term outcomes are achieved through ASK SAD, which removes RC irritation within the narrowed subacromial space. RC reconstruction or sutures, which can be performed arthroscopically quite easily, are indicated in type II lesions. The situation is similar in type III lesions, where, from a technical point of view, reconstruction is facilitated by ASK-assisted reconstruction with mini-incision. Since type IV lesions are the most complex ones, the largest number of surgical management methods is described here. As for muscle transfer, the subscapularis and latissimus dorsi muscles are used most often, the latter requiring wider surgical access. Partial non-anatomical reconstruction is useful, too. New synthetic prostheses, as well as biosynthetic or biologic prostheses prepared with cultures of pluripotent stem cells, have been developed recently. Unlike some other authors, we prefer open surgery. Attempts at ASK reconstruction increase surgical time considerably, while the cosmetic effect is negligible if many ASK ports are used. Reconstruction is contraindicated in type V lesions; good outcomes are being achieved with ASK palliative resection of RC remnants (Apoil). Type I lesions are successfully managed with ASK SAD. The method of choice in type II lesions is ASK reconstruction. In type III lesions, we have been getting good results with ASK-assisted RC reconstruction with mini-incision. As for type IV lesions in older patients, we have good experience with muscle transfer of a part of the intact subscapularis muscle tendon (Karas); partial non-anatomial reconstruction (Burkhart) is deemed more beneficial in younger and more active patients. For anatomical reasons, a combination of both above-mentioned methods had to be used in some cases. ASK palliative resection of RC remnants, rarely followed by resurfacing when unsuccessful, remains the method of choice in treating type V lesions. Key words: shoulder arthroscopy, rotator cuff lesions, classification, subacromial decompression, reconstruction, open surgery, palliative resection, Constant Functional Score.