Ebert-Fillmer S, Bloos U T, El Masri S, Stangl R
Klinik für Unfall‑, Schulter- und Wiederherstellungschirurgie, Sportmedizin und Sporttraumatologie, Sana Krankenhaus Rummelsberg, Rummelsberg 71, 90592, Schwarzenbruck, Deutschland.
Unfallchirurg. 2019 Jul;122(7):544-554. doi: 10.1007/s00113-018-0557-9.
Is transfer of the latissimus dorsi muscle (LDT) a good option in older patients with irreparable posterosuperior rotator cuff tears?
In 2010-2016 a total of 25 patients without glenohumeral arthritis and non-reconstructable supraspinatus and infraspinatus tendons, a recentered glenohumeral joint with remaining function in anteversion and irreparable posterosuperior rotator cuff defects were treated using LDT at the Rummelsberg Hospital. Of the patients 9 (36%) had in the past 1 or more attempts at reconstruction of the rotator cuff. All other patients (64%) underwent a primary reconstruction using LDT. The patients had an average age of 61 years and average follow up of 32 months. Of the 25 patients 24 (96%) were clinically followed up with the constant score (CS) and the visual analogue scale (VAS). The operation was performed in the technique described by Gerber to raise the latissimus dorsi but in the beach-chair position. Follow-up treatment was performed for 6 weeks using the ACRO-Assist splint (shoulder brace) in 90 ° abduction with daily limited external rotation exercises, followed by a regular regular rehabilitation on an outpatient basis.
The average operating time was 112 min (68-199 min). Postoperatively the only complication was an tightly sutured drainage. The preoperative Constantpoint averaged 25 (2-59). The postoperative Constantpoint was 60. The average gain of improvement was 35 points. The age-corrected relative CS was 74 after surgery. Pain perception improved significantly from preoperatively severe to very severe pain to postoperatively minor to no pain. In the VAS score there was a reduction from preoperatively 6 to postoperatively 3 VAS points. The external rotation improved from average 3 points in the CS to 6 points in the CS. The preoperative Constantpoint in patients <60 years (n = 12) was 20, the postoperative 51. The gain was 31 Constantpoints. In patients ≥60 years (n = 12), the preoperative Constantpoint was 31, the postoperative 60. The gain was 29 points. The difference between the age groups was not significant. Previously operatively treated patients (arthroscopic or mini-open reconstruction) all showed an improvement in Constantpoints (26 vs. 32 in primarily non-reconstructed patients); however, on a lower level (45 points in previously operated patients vs. 69 CS points).
With appropriate patient selection, a high gain in CS can be achieved even in older patients using latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. The VAS score and external rotation significantly improved. Previously attempts in rotator cuff reconstruction demonstrated a negative influence on the clinical outcome.
对于患有不可修复的肩袖后上部撕裂的老年患者，背阔肌转移术（LDT）是否是一个好的选择？
2010年至2016年期间，鲁默尔斯贝格医院对25例无盂肱关节炎、冈上肌和冈下肌肌腱不可重建、盂肱关节已重新定位且前屈功能尚存以及存在不可修复的肩袖后上部缺损的患者进行了背阔肌转移术治疗。其中9例（36%）患者过去曾有1次或多次肩袖重建尝试。所有其他患者（64%）接受了初次背阔肌转移重建术。患者平均年龄61岁，平均随访32个月。25例患者中有24例（96%）接受了临床随访，采用了Constant评分（CS）和视觉模拟量表（VAS）。手术采用Gerber描述的技术进行，在沙滩椅位抬起背阔肌。术后使用ACRO-Assist夹板（肩部支具）在90°外展位进行6周的随访治疗，每日进行有限的外旋练习，随后进行常规门诊康复。
平均手术时间为112分钟（68 - 199分钟）。术后唯一的并发症是引流管缝合过紧。术前Constant评分平均为25分（2 - 59分）。术后Constant评分为60分。平均改善幅度为35分。术后年龄校正后的相对CS为74分。疼痛感知从术前的重度至极重度疼痛显著改善为术后的轻度至无疼痛。在VAS评分中从术前的6分降至术后的3分。外旋功能从CS评分中的平均3分提高到6分。年龄<60岁（n = 12）患者术前Constant评分为20分，术后为51分。改善幅度为31分。年龄≥60岁（n = 12）患者术前Constant评分为31分，术后为60分。改善幅度为29分。年龄组之间差异不显著。先前接受过手术治疗的患者（关节镜或小切口重建）Constant评分均有改善（初次未重建患者为26分，而这些患者为32分）；然而，改善程度较低（先前手术患者为45分，而初次未重建患者为69分）。
通过适当选择患者，即使是老年患者，采用背阔肌转移术治疗不可修复的肩袖后上部撕裂也可实现较高的CS评分改善。VAS评分和外旋功能显著改善。先前的肩袖重建尝试对临床结果有负面影响。
