Chalmers Peter N, Saltzman Bryan M, Feldheim Terrence F, Mascarenhas Randy, Mellano Chris, Cole Brian J, Romeo Anthony A, Nicholson Gregory P
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
J Shoulder Elbow Surg. 2015 Jul;24(7):1028-35. doi: 10.1016/j.jse.2014.12.014. Epub 2015 Feb 2.
In the treatment of long thoracic nerve palsy with pectoralis major transfer, it remains unknown whether direct transfer of the pectoralis to the scapula or indirect transfer with an interpositional graft provides superior outcomes.
A 3-tiered study was performed to gain a comprehensive understanding. (1) A survey of the membership of the American Shoulder and Elbow Surgeons (ASES) was conducted to reach a Level V consensus. (2) A systematic review was conducted to identify all series evaluating direct and indirect transfer of the pectoralis major tendon to create a Level IV consensus. (3) A retrospective review was performed to provide Level III evidence.
(1) Surgeons were evenly split between whole and split tendon transfers, direct and indirect transfers, and graft types. More experienced surgeons were more likely to prefer an indirect transfer. (2) Analysis of 10 Level IV studies (131 shoulders) revealed that patients who underwent indirect transfer were significantly more likely to develop recurrent winging (P = .009) and had lower active forward elevation (P < .001) and ASES scores (P = .0016). (3) Twenty-four patients were included in our retrospective review with a mean follow-up of 4.3 years (77% follow-up), of whom 14 underwent indirect transfer and 10 underwent direct transfer. There were no significant differences in recurrence of winging, range of motion, or ASES scores.
Level V and III evidence suggests that there is no functional difference between direct and indirect transfer. Level IV evidence must be interpreted with caution.
在采用胸大肌转移治疗胸长神经麻痹时，胸大肌直接转移至肩胛骨还是通过植入移植物进行间接转移是否能带来更好的效果仍不明确。
进行了一项三层研究以全面了解情况。（1）对美国肩肘外科医师学会（ASES）成员进行了调查，以达成V级共识。（2）进行了系统评价，以确定所有评估胸大肌腱直接和间接转移的系列研究，从而形成IV级共识。（3）进行了回顾性研究以提供III级证据。
（1）在整块肌腱转移与劈开肌腱转移、直接转移与间接转移以及移植物类型之间，外科医生的意见平分秋色。经验更丰富的外科医生更倾向于间接转移。（2）对10项IV级研究（131例肩部病例）的分析显示，接受间接转移的患者出现复发性翼状肩胛的可能性显著更高（P = 0.009），主动前屈抬高更低（P < 0.001），ASES评分更低（P = 0.0016）。（3）我们的回顾性研究纳入了24例患者，平均随访4.3年（随访率77%），其中14例接受间接转移，10例接受直接转移。在翼状肩胛复发、活动范围或ASES评分方面无显著差异。
V级和III级证据表明直接转移和间接转移在功能上无差异。对IV级证据的解读必须谨慎。
