Nian Patrick P, Pujari Amit, Duey Akiro H, Palosaari Andrew A, Levy Kenneth H, Bernstein Jordan, Cagle Paul J
SUNY Downstate Health Sciences University College of Medicine, Brooklyn, NY 11203, USA.
Icahn School of Medicine at Mount Sinai, New York City, New York, 10029, USA.
J Orthop. 2024 Oct 28;63:48-57. doi: 10.1016/j.jor.2024.10.035. eCollection 2025 May.
The relative clinical advantages of reverse shoulder arthroplasty (RSA) with latissimus dorsi transfer (LDT) in direct comparison to RSA with latissimus dorsi and teres major (LD and TM) transfer for the treatment of combined loss of elevation and external rotation (CLEER) are not well understood. The objective of this study was to conduct a systematic review and meta-analysis to compare the two surgeries with regards to (1) preoperative severity/indications, (2) range of motion (ROM) outcomes, (3) functional and patient-reported outcomes (PROs), and (4) complications.
Following screening of three databases in accordance with PRISMA guidelines, 13 studies were included, consisting of 91 and 115 shoulders having received RSA with LDT and with LD and TM, respectively. The primary outcome was the change in external rotation. Secondary outcomes included preoperative Hamada grade and Goutallier score, abduction, forward elevation, and internal rotation, American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley Score (CMS), Simple Shoulder Test (SST), Simple Shoulder Value (SSV), Visual Analog Score (VAS) for pain, and major/minor complications, where available. Meta-analysis was performed using a random-effects model. P-values less than 0.05 were considered statistically significant.
RSA with LD and TM was utilized more often than RSA with LDT for patients with higher preoperative Hamada grade (p = 0.010) and lower subscapularis Goutallier score (p = 0.015). RSA with LDT was associated with a greater improvement in abduction compared to RSA with LD and TM (75.3 versus 55.6°, p < 0.010), but had comparable changes in external rotation, forward elevation, or internal rotation. RSA with LDT was associated with a greater improvement in CMS compared to RSA with LD and TM (44.1 versus 36.4 points, p < 0.010). RSA with LDT was associated with a lower rate of major complications compared to RSA with LD and TM (7.1 versus 20.2 %, p = 0.032).
While improvements of external rotation were comparable, RSA with LDT may offer superior improvement in abduction and CMS, and lower rates of major complications compared to RSA with LD and TM in patients with CLEER. Orthopaedic surgeons may consider these findings in their surgical plan according to a patient's unique anatomy and clinical indications.
IV, Systematic Review and Meta-analysis of Level I-IV Studies.
背阔肌转移（LDT）的反式肩关节置换术（RSA）与背阔肌和大圆肌（LD和TM）转移的RSA在治疗上举和外旋联合丧失（CLEER）方面的相对临床优势尚未得到充分了解。本研究的目的是进行一项系统评价和荟萃分析，以比较这两种手术在以下方面的情况：（1）术前严重程度/适应症；（2）活动范围（ROM）结果；（3）功能和患者报告结果（PROs）；（4）并发症。
按照PRISMA指南筛选三个数据库后，纳入了13项研究，分别包括91例和115例接受LDT的RSA以及接受LD和TM的RSA的肩部。主要结局是外旋的变化。次要结局包括术前滨田分级和古塔利耶评分、外展、前屈上举和内旋、美国肩肘外科医师学会（ASES）评分、Constant-Murley评分（CMS）、简易肩关节测试（SST）、简易肩关节值（SSV）、疼痛视觉模拟评分（VAS）以及主要/次要并发症（如适用）。采用随机效应模型进行荟萃分析。P值小于0.05被认为具有统计学意义。
对于术前滨田分级较高（p = 0.010）和肩胛下肌古塔利耶评分较低（p = 0.015）的患者，与LDT-RSA相比，LD和TM-RSA的使用频率更高。与LD和TM-RSA相比，LDT-RSA在外展方面的改善更大（75.3°对55.6°，p < 0.......此处原文有误，应为p < 0.010），但在外旋、前屈上举或内旋方面的变化相当。与LD和TM-RSA相比，LDT-RSA在CMS方面的改善更大（44.1分对36.4分，p < 0.010）。与LD和TM-RSA相比，LDT-RSA的主要并发症发生率较低（7.1%对20.2%，p = 0.032）。
虽然外旋的改善相当，但在CLEER患者中，与LD和TM-RSA相比，LDT-RSA在外展和CMS方面可能有更好的改善，且主要并发症发生率较低。骨科医生在制定手术计划时可根据患者独特的解剖结构和临床适应症考虑这些发现。
IV，I-IV级研究的系统评价和荟萃分析。
