Department of Orthopaedic Surgery & Sports Traumatology, Hôpital de L'Archet II, Medical University of Nice-Sophia Antipolis, Nice, France.
J Shoulder Elbow Surg. 2010 Mar;19(2 Suppl):20-30. doi: 10.1016/j.jse.2009.12.011.
In patients with a rotator cuff-deficient shoulder, a combined loss of active elevation and external rotation (CLEER) can occur when both the infraspinatus and teres minor muscles are absent. A reverse shoulder arthroplasty (RSA) can restore active elevation in these patients but cannot restore active external rotation because there are no other external rotator cuff muscles. We hypothesized that a modified L'Episcopo procedure (latissimus dorsi [LD] and teres major [TM] transfer) with a simultaneous RSA would restore shoulder function and activities of daily living (ADLs).
Seventeen consecutive patients (mean age, 71 years) with CLEER underwent this combined procedure through a single deltopectoral approach and were prospectively monitored for at least 12 months. All patients had severe cuff tear arthropathy and advanced atrophy or fatty infiltration of the infraspinatus/teres minor muscles on preoperative magnetic resonance imaging or computed tomography scans. The patients were immobilized in 30 degrees of abduction and external rotation for 6 weeks postoperatively before starting rehabilitation.
Mean active elevation increased from 74 degrees preoperatively to 149 degrees postoperatively (+75 degrees ), and external rotation increased from -21 degrees to 13 degrees (+34 degrees ). Patient satisfaction, subjective shoulder value, Constant-Murley scores and ADLs all improved significantly. DISCUSSION & CONCLUSIONS: In patients with CLEER, the association of RSA with LD/TM transfer restores active elevation and external rotation. The combined procedure, performed in the same session through a deltopectoral approach, is indicated in a selected subgroup of patients with a rotator cuff-deficient shoulder and an absent or atrophied infraspinatus/teres minor muscles. Our technique is easier to perform than the two-incision procedure and appears to avoid problems such as extensive scarring, adhesions and axillary nerve lesions. Transferring both the LD and TM, rather than the LD alone, results in better active external rotation.
在肩袖缺失的患者中，如果冈下肌和小圆肌同时缺失，可能会出现主动抬高和外旋（CLEER）联合丧失。反肩置换术（RSA）可以恢复这些患者的主动抬高，但不能恢复主动外旋，因为没有其他外旋肩袖肌肉。我们假设改良的 L'Episcopo 手术（背阔肌[LD]和大圆肌[TM]转移）联合 RSA 可以恢复肩部功能和日常生活活动（ADL）。
17 例连续 CLEER 患者（平均年龄 71 岁）通过单一肩峰下入路接受了该联合手术，并进行了至少 12 个月的前瞻性监测。所有患者均有严重的肩袖撕裂性关节炎，术前磁共振成像或计算机断层扫描显示冈下肌/小圆肌严重撕裂、萎缩或脂肪浸润。术后患者用 30 度外展和外旋固定 6 周，然后开始康复。
主动抬高从术前的 74 度增加到术后的 149 度（增加 75 度），外旋从-21 度增加到 13 度（增加 34 度）。患者满意度、主观肩部值、Constant-Murley 评分和 ADL 均显著提高。
在 CLEER 患者中，RSA 联合 LD/TM 转移可恢复主动抬高和外旋。通过肩峰下入路在同一手术中进行的联合手术，适用于肩袖缺失且冈下肌/小圆肌缺失或萎缩的特定患者亚组。我们的技术比双切口手术更容易操作，似乎可以避免广泛的疤痕、粘连和腋神经损伤等问题。同时转移 LD 和 TM，而不是仅转移 LD，可获得更好的主动外旋。
