Institut Universitaire Locomoteur et Sport (iULS), Hôpital Pasteur 2, University of Nice Sophia Antipolis (UNSA), Nice, France.
Sydney Adventist Hospital, Wahroonga, NSW, Australia.
J Shoulder Elbow Surg. 2018 Mar;27(3):499-509. doi: 10.1016/j.jse.2017.07.008. Epub 2017 Dec 28.
The purpose of this study was to characterize a subgroup of cuff-deficient patients with isolated loss of active external rotation (ILER) but preserved active elevation and to evaluate the outcomes of the L'Episcopo procedure to restore horizontal muscle balance.
During a 10-year period, 26 patients (14 men, 12 women) were identified with ILER in the setting of massive irreparable posterosuperior cuff tears. A modified L'Episcopo tendon transfer was performed to restore active external rotation and to improve shoulder function. The mean age at surgery was 64.5 years (29-83 years). Patients were evaluated with a mean follow-up of 52 months (range, 24-104 months).
Preoperatively, despite maintained active elevation (average of 161°), ILER patients complained about loss of spatial control of the arm and difficulties with activities of daily living. On computed tomography scan or magnetic resonance imaging, there was severe fatty infiltration of infraspinatus and absent or atrophic teres minor. After L'Episcopo transfer, 84% of patients were satisfied. The gain in active external rotation was +26° in arm at the side and +18.5° in 90° abduction. Adjusted Constant score and Simple Shoulder Value increased from 63.6% to 86.9% and from 36.9% to 70.8%, respectively (P < .001). The ADLER score increased from 10 to 24.5 points (P < .002). Two patients with advanced cuff tear arthropathy (Hamada stage 3 and 4) required conversion to a reverse shoulder arthroplasty (RSA) 7 and 9 years after the index surgery.
ILER is a distinct entity that is a cause of severe handicap because of loss of spatial control of the upper limb. This symptom is related to absent or atrophied infraspinatus and teres minor. In properly selected cases (Hamada stage 1 or 2), the modified L'Episcopo transfer is effective at restoring anterior-posterior rotator cuff force balance. In more advanced cuff tear arthropathy (Hamada stage ≥3), the tendon transfer should be performed with an RSA because of possible secondary degeneration of the glenohumeral joint.
本研究旨在描述一组袖缺损患者中存在孤立性主动外旋丧失（ILER）但保留主动抬高功能的亚组，并评估 L'Episcopo 手术恢复水平肌肉平衡的效果。
在 10 年期间，26 名（14 名男性，12 名女性）患有巨大不可修复的后上肩袖撕裂的患者被确定为 ILE 患者。进行改良 L'Episcopo 肌腱转移以恢复主动外旋并改善肩部功能。手术时的平均年龄为 64.5 岁（29-83 岁）。患者的平均随访时间为 52 个月（范围，24-104 个月）。
尽管术前保持了主动抬高（平均 161°），但 ILE 患者仍抱怨手臂空间控制丧失和日常生活活动困难。在 CT 扫描或 MRI 上，发现肩胛下肌严重脂肪浸润，小圆肌缺失或萎缩。L'Episcopo 转移后，84%的患者满意。主动外旋的增加量为肩侧+26°和 90°外展位+18.5°。调整后的 Constant 评分和简易肩部评分分别从 63.6%增加到 86.9%和从 36.9%增加到 70.8%（P<.001）。ADLER 评分从 10 分增加到 24.5 分（P<.002）。2 名肩袖撕裂性关节炎进展患者（Hamada 3 期和 4 期）在指数手术后 7 年和 9 年分别需要转换为反向肩关节置换术（RSA）。
ILER 是一种明显的实体，由于上肢空间控制丧失而导致严重残疾。这种症状与缺失或萎缩的肩胛下肌和小圆肌有关。在适当选择的病例（Hamada 1 期或 2 期）中，改良的 L'Episcopo 转移可有效恢复前后旋转袖的力量平衡。在更严重的肩袖撕裂性关节炎（Hamada 分级≥3 期）中，由于可能继发肱骨头关节退行性变，应进行肌腱转移联合 RSA。
