Oztürk Kahraman, Bülbül Murat, Demir Bilal Birkan, Büyükkurt Cem Dinçay, Ayanoğlu Semih, Esenyel Cem Zeki
Department of Orthopedics and Traumatology, Vakıf Gureba Training and Research Hospital, İstanbul.
Acta Orthop Traumatol Turc. 2010;44(3):186-93. doi: 10.3944/AOTT.2010.2332.
We evaluated the results of latissimus dorsi and teres major tendon transfer to the rotator cuff together with musculotendinous lengthening of the subscapularis and/or pectoralis major muscles in patients with internal rotation contracture and decreased external rotation and abduction secondary to obstetrical brachial plexus palsy.
Thirty patients (18 boys, 12 girls; mean age 9 years; range 4 to 15 years) with internal rotation contracture and loss of external rotation and abduction of the shoulder secondary to obstetrical brachial plexus palsy underwent transfer of the latissimus dorsi/teres major tendons to the rotator cuff. In addition, musculotendinous lengthening of the subscapularis and pectoralis major (n=15), pectoralis major (n=9), and subscapularis (n=6) were performed. Nine patients had upper plexus involvement (C5-6), 14 had C5-7 involvement, and seven had complete plexus involvement (C5-T1). According to the Waters and Peljovich classification, all the patients had a congruent glenohumeral joint, which was classified as type 1 in one patient, type 2 in 15 patients, and type 3 in 14 patients. Pre- and postoperative range of motion values of the patients were measured and their motor functions were evaluated with the Mallet scoring system. The mean follow-up period was 47.8 months (range 9 to 84 months).
Preoperatively, the mean active abduction was 75.8°, and the mean active external rotation was 25.2°. Postoperatively, the mean abduction and external rotation increased to 138.3° (by 62.5°, 82.5%) and 76.4 degrees (by 51.2°, 203.2%), respectively. Improvements in the degrees of abduction and external rotation were significant (p=0.000). According to the Mallet scoring system, the mean preoperative global abduction and global external rotation scores were 2.97 and 2.43, respectively; the mean Mallet scores for the ability to move the hand to the mouth, neck, and back were 2.50, 2.17, and 2.67, respectively. Postoperatively, the mean global abduction score increased to 3.97 (by 33.7%, p=0.000), and the mean global external rotation score increased to 3.77 (by 55.1%, p=0.000). The mean scores for the ability to move the hand to the mouth, neck, and back were 3.30 (increased by 32%, p=0.000), 3.73 (increased by 71.9%, p=0.000), and 2.30 (decreased by 13.9%, p=0.003), respectively. Postoperative changes in the Mallet scores were all significant. Improvements in abduction and external rotation were not significant between patients ≤ 9 years and > 9 years of age (p > 0.05).
Transfer of the latissimus dorsi and teres major tendons to the rotator cuff combined with musculotendinous lengthening of the subscapularis and/or pectoralis major provides satisfactory increases in shoulder abduction and external rotation, regardless of the age, in patients with no or minimal glenohumeral joint incongruency.
我们评估了背阔肌和大圆肌腱转移至肩袖，同时对肩胛下肌和/或胸大肌进行肌腱延长术，用于治疗因产瘫性臂丛神经麻痹导致内旋挛缩、外旋及外展功能减退患者的疗效。
30例（18例男孩，12例女孩；平均年龄9岁；范围4至15岁）因产瘫性臂丛神经麻痹导致内旋挛缩、肩关节外旋及外展功能丧失的患者接受了背阔肌/大圆肌腱转移至肩袖的手术。此外，分别对15例患者的肩胛下肌和胸大肌、9例患者的胸大肌以及6例患者的肩胛下肌进行了肌腱延长术。9例患者为上干型（C5 - 6），14例为C5 - 7型，7例为全臂丛型（C5 - T1）。根据Waters和Peljovich分类法，所有患者的盂肱关节均匹配，其中1例为1型，15例为2型，14例为3型。测量患者术前和术后的活动度值，并使用Mallet评分系统评估其运动功能。平均随访时间为47.8个月（范围9至84个月）。
术前，平均主动外展为75.8°，平均主动外旋为25.2°。术后，平均外展和外旋分别增加至138.3°（增加62.5°，82.5%）和76.4°（增加51.2°，203.2%）。外展和外旋角度的改善具有显著性（p = 0.000）。根据Mallet评分系统，术前整体外展和整体外旋的平均评分分别为2.97和2.43；手向口、颈部和背部移动能力的平均Mallet评分分别为2.50、2.17和2.67。术后，整体外展平均评分增至3.97（增加33.7%，p = 0.000），整体外旋平均评分增至3.77（增加55.1%，p = 0.000）。手向口、颈部和背部移动能力的平均评分分别为3.30（增加32%，p = 0.000）、3.73（增加71.9%，p = 0.000）和2.30（降低13.9%，p = 0.003）。术后Mallet评分的变化均具有显著性。年龄≤9岁和＞9岁的患者在外展和外旋改善方面差异无显著性（p＞0.05）。
对于盂肱关节无或仅有轻微不匹配的患者，无论年龄大小，背阔肌和大圆肌腱转移至肩袖联合肩胛下肌和/或胸大肌肌腱延长术可使肩关节外展和外旋得到满意改善。
