Tytgat Hannes, Macdonald Peter, Verhaegen Filip
AZ St. Dimpna Geel, J.-B. Stessenstraat 2, 2440 Geel, Belgium.
Pan Am Clinic, Winnipeg, MB, R3M 3E4, Canada; Department of Surgery, Section of Orthopaedic Surgery, University of Manitoba, Winnipeg, MB, R3A 1R9, Canada.
J ISAKOS. 2024 Feb;9(1):53-58. doi: 10.1016/j.jisako.2023.10.010. Epub 2023 Oct 23.
Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.
急性肩胛下肌（SSC）撕裂的一期修复效果良好，但肌腱回缩、肌肉萎缩、脂肪浸润和肱骨头移位可能导致更为陈旧性的撕裂无法修复。这些无法修复的SSC撕裂给骨科医生带来了诊断和治疗方面的挑战。仔细的体格检查和影像学评估有助于区分可修复与不可修复的撕裂，但由于现有证据的方法学局限性，它们仍然不太可靠。因此，未来有必要采用三维和定量测量技术进行研究，以更好地预测SSC的不可修复性。当对无法修复的SSC撕裂进行保守治疗失败时，反肩关节置换术已被确立为患有骨关节炎的老年、低需求患者的首选治疗方案，能可靠地改善疼痛和功能。在没有明显骨关节炎的年轻患者中，肌肉肌腱转移术是首选治疗方法。胸大肌转移术历来是最常施行的手术，可改善活动范围并缓解疼痛，但无法充分恢复力量和肩部功能。由于其生物力学优势，背阔肌转移术在过去几年中受到越来越多的关注，早期临床研究也表明其效果有所改善。最近，有人提出前关节囊重建术可作为肌肉肌腱转移术的替代方法，但完全缺乏临床数据。未来有必要进行高质量的随机对照试验，以可靠地比较不同的肌肉肌腱转移术和前关节囊重建术。
