PURPOSE OF THE STUDY: 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. MATERIAL: 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. METHODS: 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. RESULTS: 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.
PURPOSE OF THE STUDY In a retrospective study we evaluated the results of plate osteosynthesis for treatment of periprosthetic femoral fractures classified as Vancouver types B1 and B2. MATERIAL AND METHODS The group comprised 19 patients with post-operative periprosthetic fractures treated by open reduction and internal fixation with plate osteosynthesis at our department between the beginning of 2004 and June 2007. Perioperative fractures were not included. The average age of the patients was 72.0 (range, 53 to 88) years. A locking compression plate (PCL) was used in 16 patients. The average follow-up was 21 months, with 6 months at least. We evaluated radiographs of the fracture and, in the majority of cases, also those before a periprosthetic fracture occurred. We focussed on the signs of potential femoral component loosening and the course of fracture line; fractures were classified according to the Vancouver classification system. Follow-up included both clinical and radiographic examination. RESULTS Thirteen patients showed bone union and a good functional outcome. One patient was present at follow-up only once and was not included in the final evaluation. Non-union was recorded in five patients (27.7 %), marked implant migration occurred in three (all had type B2 fracture) and osteosynthesis failed in two patients. DISCUSSION We consider the Vancouver classification to be the most suitable classification system. The relatively high proportion of non-union fractures can be accounted for by an inappropriate indication for osteosynthesis in fractures with stem loosening.The assessment of stem stability based on a radiograph only may, in some cases, be questionable;therefore, if doubtful, we prefer an intra-operative evaluation of implant stability. We also discuss a contribution of angle-stable plates to the osteosynthesis of periprosthetic fractures as well as their bone fixation technique. CONCLUSIONS Plate osteosynthesis is a suitable method for treatment of periprosthetic fractures if there is a stable femoral component. LPC implants are not discriminative enough in the range of indications for plate osteosynthesis.The use of plate osteosynthesis in a total hip arthroplasty with signs of loosening is bound to lead to acceleration of loosening and stem migration, and may even result in plate breakage or its expulsion. This implies that, in such THAs, plate osteosynthesis can only be carried out as a palliative procedure in immobile and severely ill old patients.
- MeSH
- fraktury femuru MeSH
- fraktury kostí MeSH
- fraktury kyčle chirurgie MeSH
- hojení fraktur MeSH
- kostní destičky MeSH
- kyčelní protézy škodlivé účinky MeSH
- lidé středního věku MeSH
- lidé MeSH
- náhrada kyčelního kloubu metody škodlivé účinky MeSH
- reoperace MeSH
- selhání protézy MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- vnitřní fixace fraktury MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- hodnotící studie MeSH
- následné studie MeSH
- retrospektivní studie MeSH
BACKGROUND AND AIMS: At present, revision surgery of a total hip replacement is a major problem that must be dealt with by all orthopedic facilities. Aseptic loosening of the acetabular component is often associated with destruction of the original spherical shape of the acetabulum and the formation of bone defects. An orthopedist faces the challenge of acetabular revision and stable fixation of the new acetabular component in an effort to re-establish the functioning of the hip replacement. MATERIAL AND METHODS: The authors evaluated a group of 74 patients in whom they implanted an oblong revision cup due to aseptic loosening of the acetabular component from August 2000 until December 2003. The mean duration of the follow-up period was 63 months (ranging from 38 to 78 months). RESULTS AND CONCLUSIONS: The authors reported very good results from the use of this implant, where osteointegration and good functional outcome evaluated according to the Harris Hip Score (HHS) were achieved in 95% of cases. The long-term outcome should be the subject of further investigation.
- MeSH
- artróza kyčelních kloubů chirurgie MeSH
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- náhrada kyčelního kloubu škodlivé účinky MeSH
- následné studie MeSH
- nekróza hlavice femuru etiologie chirurgie radiografie MeSH
- protézy - design MeSH
- protézy a implantáty MeSH
- reoperace přístrojové vybavení MeSH
- retrospektivní studie MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
PURPOSE OF THE STUDY The aim of this study is to present a simple rotator cuff lesion classification that provides guidelines as to their treatment, and to evaluate the results of palliative arthroscopic resection of rotator cuff residues known as unreconstructible lesions. In addition, our therapeutic approaches were ascertained in view of their applicability to the types of lesions studied. MATERIAL In a five-year period (January 1, 2000 to December 31, 2004), a total of 181 arthroscopic procedures were performed on the shoulder joints of patients diagnosed with impingement or rotator cuff syndromes. In 130 cases, a tear or irritation of the rotator cuff was recorded. Rotator cuff lesions were categorized on the basis of our modification of the Gschwend classification. In 15 of the patients, in whom unreconstructible lesions were detected, arthroscopic palliative resection of rotator cuff residues was performed. The average age of these patients was 65 years, and they were followed up for 6 to 60 months. METHODS All surgery was carried out in a "beach-chair" position, either under general anesthesia or with an interscalene brachial plexus block. The arthroscope was inserted through the "soft-spot". Continuous irrigation was provided with an arthroscopic pump. In the first place, the glenohumeral joint was explored, and resection of rotator cuff residues was performed via ventral and lateral ports. The procedure was completed by subacromial decompression and partial resection of the acromion.The results were evaluated by the Constant Functional Score, as modified by us. Clinical examination was supplemented with subjective information from questionnaires provided by the patients. RESULTS In a total of 130 shoulder joints with rotator cuff tears examined by arthroscopy, type I lesions were found in 90, and these were treated by arthroscopic subacromial decompression. Twenty-five type II and type III lesions underwent open rotator cuff repair and 15 type IV and type V lesions were treated by palliative arthroscopic resection of residual rotator cuff lesions, using the Apoil method. These fifteen patients were followed up for 6 to 60 months and their outcomes were evaluated. No excellent results were achieved (Constant Score, 80-100 points), but this is implicit in the nature of a palliative operation. Good (65-79 points) and satisfactory (51-64 points) results were recorded in 11 (73.3 %) and four (26.7 %) patients, respectively. No poor results were found. The average improvement in Constant scores was 21 points. DISCUSSION A total of 130 rotator cuff lesions diagnosed arthroscopically were categorized on the basis of a modified classification system. We will continue to treat type I lesions by arthroscopic subacromial decompression, which has provided good results, as reported in our previous study. We consider the arthroscopic repair of rotator cuff tears to be an optimal procedure for type II lesions; for type III lesions we will keep using open repair surgery. The most complex problem is presented by type IV lesions. While palliative arthroscopic resection of the rotator cuff is one option, muscle transfer has also shown satisfactory outcomes, as has partial reconstruction. The use of either allografts or cadaver grafts did not give good results. Type V lesions, in our opinion, are unambiguously indicated for palliative arthroscopic resection of the rotator cuff. Their treatment by the Apoil method and detailed evaluation of the outcomes are described here; the results of this study are in agreement with those reported in the relevant international literature. CONCLUSIONS Good and satisfactory results were achieved by palliative arthroscopic resection of the rotator cuff, in combination with subacromial decompression, in patients with unreconstructible lesions. The average improvement in the Constant Functional Score was 21 points. This suggests that the method can be recommended for wider use in the future. However, exact diagnosis and correct indication, i.e., type V lesion, are essential.
- MeSH
- acetabulum chirurgie patofyziologie účinky léků MeSH
- lidé MeSH
- náhrada kyčelního kloubu klasifikace metody statistika a číselné údaje MeSH
- replantace klasifikace metody využití MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- srovnávací studie MeSH
- MeSH
- cyklodextriny chemie MeSH
- fluorescenční spektrometrie využití MeSH
- porfyriny chemie MeSH
- Publikační typ
- techniky in vitro MeSH
