http://www.revistadechimie.ro REV.CHIM.(Bucharest)♦69♦No. 9 ♦2018 2508 The Challenges of Arthroscopic Diagnosis of Subscapularis Tears EMIL GEORGE HARITINIAN 1, 2 *, BOGDAN SENDREA 2 , LAURENT NOVE JOSSERAND 3 1 Carol Davila University of Medicine and Pharmacy Bucharest, 8 Eroii Sanitari Blvd., 050474, Bucharest, Romania 2 Foisor Hospital of Orthopaedics, Trauma and Osteoarticular Tuberculosis, 35-37 Ferdinand Blvd., 021382, Bucharest, Romania 3 Centre Orthopedique Santy, Avenue Paul Santy 24, 69008 Lyon, France Ramsay, Generale de Sante, Hopital Prive Jean Mermoz, Avenue Jean Mermoz 55, 69008 Lyon, France Visualisation of subscapularis lesions is difficult during open surgery. Introduction of arthroscopic procedures for rotator cuff surgery improved the diagnosis of subscapularis tears, but it still can be more challenging than for other rotator cuff tendon tears. The SFA classification of subscapularis tears is reproducible and correlates well with the arthroscopic findings. The arthroscopic diagnosis of subscapularis tear is made easier by: shoulder internal rotation, biceps tenodesis, dissection of the rotator interval, recognition of the sentinel and comma signs. Keywords: Subscapularis tears, subscapularis arthroscopic, subscapularis diagnosis There are significant differences between the anatomical characteristics of the subscapularis tendon compared to the supraspinatus and the infraspinatus tendons [1]. From an anatomical point of view the subscapularis can be divided into several parts. The uppermost part forms the floor of the most proximal part of the bicipital pulley groove. It attaches to the upper margin of the lesser tuberosity, sends a thin tendinous slip to the fovea capitis of the humerus [2] and has connexions with fibres of the supraspinatus tendon and coracohumeral ligament [3, 4]. The superior and middle parts have deep fibres which insert on the lesser tuberosity and the floor of the bicipital groove and superficial fibres traversing over the biceps to insert on the greater tuberosity [5]. The inferior part consists of muscle fibres attaching directly to the distal lesser tuberosity on a narrow vertical footprint [1]. Most of the lesions begin at the superior part of the subscapularis tendon. These lesions, associated with supraspinatus tendon tears, are difficult to visualize during open surgery. The subscapularis tears with an intact biceps pulley or rotator interval, the so-called hidden lesions , can be diagnosed in open surgery only after the opening of the rotator interval [6]. The introduction of arthroscopic procedures for rotator cuff surgery improved the diagnosis of subscapularis tears, especially for the more subtle lesions like longitudinal tears of the superior part and partial-thickness transverse tears [7, 8]. The arthroscopic diagnosis can be more challenging than for other rotator cuff tendons tears and the complete visualization of the hidden lesions of the subscapularis tears may require removal of the rotator interval and medial pulley [9]. New advances in the field, like the use of a computer navigation system and haptic robotic shoulder arthroscopy could further improve the diagnosis and treatment of subscapularis tears [10-13]. The long head of the biceps tendon is usually unstable and pathologic in cases of subscapularis tendon tears associated with lesions of the superior glenohumeral ligament/coracohumeral ligament complex [ 14]. Our primary objective was to evaluate if the subscapularis tears classification of the French Society of Arthroscopy (SFA) [1] is reproducible, correlates well with the patterns of tears encountered in our clinical practice and allows for comparison of the epidemiological and * email: haritinian@gmail.com; Phone:+ 4072899823 outcome data. The secondary objective was to define methods of improving the arthroscopic diagnosis of subscapularis tears. Experimental part The preoperative evaluation included a clinical examination, of great importance being the lift-off [15], the belly press [16] and the bear hug [17] tests. Conventional shoulder radiographies, arthro-CT and MRI scans, stored in the local PACS, were also part of the preoperative evaluation [18]. All shoulder arthroscopies were performed in the beach- chair position, with general anaesthesia and inter-scalene nerve block. Relevant images and videos of the subscapularis tears were recorded, all patients provided informed consent. Each identified subscapularis tear was categorized using the SFA classification. Four types were described in the SFA arthroscopic classification [1] of subscapularis tears: -Type 1-a normal anterior sling wall with partial subscapularis tendon detachment at the articular side of the superior tendon -Type 2 - a combined partial subscapularis separation from the lesser tuberosity and a partial tear in the anterior sling wall. As the size increases, a delaminated tear of the subscapularis tendon (as described for the infraspinatus tendon) can be found -Type 3 - a complete subscapularis tendon detachment and a complete tear in the anterior sling wall, only the most superficial fibres remaining continuous with the sling -Type 4 - a complete detachment of the subscapularis tendon from the humerus by a full-thickness tear, leaving a free lateral edge, associated with the comma sign. Results and discussions In the type 1 SFA we included all cases in which we found a partial detachment of the subscapularis fibres from the lesser humeral tuberosity, without lesions of the bicipital pulley. This type of lesion can be diagnosed on the preoperative imagery (fig.1) and confirmed arthroscopically (fig. 2) A combined partial subscapularis separation from the lesser tuberosity associated with a partial lesion of the anterior sling wall and an intact superior glenohumeral ligament was classified as type 2 SFA. The lesion was