Erşen Ali, Ozben Hakan, Demirhan Mehmet, Atalar Ata Can, Kapıcıoğlu Mehmet
Department of Orthopaedics and Traumatology, Istanbul Medical Faculty, Istanbul University, Capa, Fatih, 34093, Istanbul, Turkey.
Clin Orthop Relat Res. 2014 Dec;472(12):3880-8. doi: 10.1007/s11999-014-3770-z.
Transfer of the latissimus dorsi tendon to the posterosuperior part of the rotator cuff is an option in active patients with massive rotator cuff tears to restore shoulder elevation and external rotation. However, it is unknown whether this treatment prevents progression of cuff tear arthropathy.
QUESTIONS/PURPOSES: The purpose of this study was to determine whether the observed improvement in shoulder function in the early postoperative period with latissimus dorsi tendon transfer for irreparable rotator cuff tears will be permanent or will deteriorate in the midterm period (at 1-5 years after surgery).
During a 6-year period, we performed 11 latissimus dorsi tendon transfers in 11 patients for patients with massive, irreparable, chronic tears of the posterosuperior part of the rotator cuff (defined as > 5 cm supraspinatus and infraspinatus tendon tears with Goutallier Grade 3 to 4 fatty infiltration on MRI), for patients who were younger than 65 years of age, and had high functional demands and intact subscapularis function. No patients were lost to followup; minimum followup was 12 months (median, 33 months; range, 12-62 months). The mean patient age was 55 years (median, 53 years; range, 47-65 years). Shoulder forward elevation, external rotation, and Constant-Murley and American Shoulder and Elbow Surgeons scores were assessed. Pain was assessed by a 0- to 10-point visual analog scale. Acromiohumeral distance and cuff tear arthropathy (staged according to the Hamada classification) were evaluated on radiographs.
Shoulder forward elevation, external rotation, Constant-Murley scores, and American Shoulder and Elbow Surgeons scores improved at 6 months. However, although shoulder motion values and Constant-Murley scores remained unchanged between the 6-month and latest evaluations, American Shoulder and Elbow Surgeons scores decreased in this period (median, 71; range, 33-88 versus median, 68; range, 33-85; p = 0.009). Visual analog scale scores improved between the preoperative and 6-month evaluations but then worsened (representing worse pain) between the 6-month and latest evaluations (median, 2; range, 0-5 versus median, 2; range, 1-6; p = 0.034), but scores at latest followup were still lower than preoperative values (median, 7; range, 4-8; p = 0.003). Although acromiohumeral distance values were increased at 6 months (median, 8 mm; range, 6-10 mm; p = 0.023), the values at latest followup (median, 8 mm; range, 5-10 mm) were no different from the preoperative ones (mean, 7 mm; range, 6-9 mm; p > 0.05). According to Hamada classification, all patients were Grade 1 both pre- and postoperatively, except one who was Grade 3 at latest followup.
The latissimus dorsi tendon transfer may improve shoulder function in irreparable massive rotator cuff tears. However, because the tenodesis effect loses its strength with time, progression of the arthropathy should be expected over time. Nevertheless, latissimus dorsi tendon transfer may help to delay the need for reverse shoulder arthroplasty for these patients.
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
对于有巨大肩袖撕裂的活动患者，将背阔肌腱转移至肩袖后上部是恢复肩关节抬高和外旋功能的一种选择。然而，这种治疗方法能否预防肩袖撕裂性关节病的进展尚不清楚。
问题/目的：本研究的目的是确定，对于不可修复的肩袖撕裂患者，术后早期通过背阔肌腱转移观察到的肩关节功能改善是永久性的，还是在中期（术后1至5年）会恶化。
在6年期间，我们对11例患者进行了11次背阔肌腱转移手术，这些患者均患有肩袖后上部巨大、不可修复的慢性撕裂（定义为冈上肌和冈下肌腱撕裂大于5cm，MRI显示Goutallier分级为3至4级脂肪浸润），年龄小于65岁，功能需求高且肩胛下肌功能完好。无患者失访；最短随访时间为12个月（中位数为33个月；范围为12至62个月）。患者平均年龄为55岁（中位数为53岁；范围为47至65岁）。评估了肩关节前屈抬高、外旋以及Constant-Murley评分和美国肩肘外科医师学会（ASES）评分。采用0至10分视觉模拟量表评估疼痛程度。通过X线片评估肩峰下间隙和肩袖撕裂性关节病（根据Hamada分类分期）。
肩关节前屈抬高、外旋、Constant-Murley评分和ASES评分在术后6个月时有所改善。然而，尽管肩关节活动度值和Constant-Murley评分在6个月和最新评估之间保持不变，但在此期间ASES评分下降（中位数，71；范围，33至88，对比中位数，68；范围，33至85；p = 0.009）。视觉模拟量表评分在术前和6个月评估之间有所改善，但在6个月和最新评估之间恶化（表示疼痛加重）（中位数，2；范围，0至5，对比中位数，2；范围，1至6；p = 0.034），但最新随访时的评分仍低于术前值（中位数，7；范围，4至8；p = 0.003）。尽管肩峰下间隙值在6个月时增加（中位数，8mm；范围，6至10mm；p = 0.023），但最新随访时的值（中位数，8mm；范围，5至10mm）与术前值（平均值，7mm；范围，6至9mm；p > 0.05）无差异。根据Hamada分类，除1例在最新随访时为3级外，所有患者术前和术后均为1级。
背阔肌腱转移可能改善不可修复的巨大肩袖撕裂患者的肩关节功能。然而，由于腱固定效应会随时间减弱，预计随着时间推移关节病会进展。尽管如此，背阔肌腱转移可能有助于延迟这些患者进行反肩置换术的时间。
IV级，治疗性研究。有关证据水平的完整描述，请参阅《作者须知》。
