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关节镜辅助下使用自体腓骨长肌移植进行下斜方肌转移治疗不可修复的肩袖后上部分撕裂

Arthroscopically Assisted Lower Trapezius Transfer Using Peroneus Longus Autograft for Irreparable Posterosuperior Rotator Cuff Tears.

作者信息

Sundararajan Silvampatti Ramasamy, Ramakanth Rajagopalakrishnan, Sujith Bandlapally Sreenivasa Guptha, Dsouza Terence, Pratheeban Karthikeyan, Rajasekaran Shanmuganathan

机构信息

Department of Arthroscopy and Sports Medicine, Ganga Medical Center & Hospitals, Coimbatore, India.

Department of Orthopedics and Spine Surgery, Ganga Medical Center & Hospitals, Coimbatore, India.

出版信息

JBJS Essent Surg Tech. 2025 Mar 18;15(1). doi: 10.2106/JBJS.ST.23.00047. eCollection 2025 Jan-Mar.

Abstract

BACKGROUND

Massive retracted rotator cuff tears are disabling in physically active patients. In patients with persistent pain in whom nonoperative treatment has failed, multiple surgical treatment options are available. Lower trapezius tendon transfer is a promising surgical procedure that can decrease pain, improve external rotation strength, and recreate more normal glenohumeral kinematics. In the present video article, we describe the surgical technique for successful arthroscopic ("scopy")-assisted lower trapezius transfer (SALTT) with use of an easily accessible peroneus longus autograft.

DESCRIPTION

The patient is positioned in a beach-chair position with the ipsilateral half of the posterior shoulder girdle included in the draping for surgical access. Joint was viewed through the standard posterior and posterolateral portals, while anterolateral and anterosuperior portals were utilized as the working portals. Subacromial and superior capsular adhesions are released, and a partial cuff repair is performed. A 3 to 4-cm vertical incision is made along the scapular spine. The superior and inferior borders of the lower trapezius are delineated and completely detached from where they insert at the scapular spine. A 3-cm vertical incision is made at the posterior border of the lateral malleolus. The fascia is incised. The peroneus longus is identified and detached with the foot in maximum dorsiflexion and eversion and is harvested with use of a closed tendon stripper. Whip stiches are placed at 1 end of the autograft. With use of a large grasping clamp, starting from the anterolateral portal and aiming toward the medial scapular incision, the autograft is shuttled and the stitched end of the autograft is fixed to the humeral head with a knotless anchor. With the shoulder in maximum external rotation and 0° of abduction, tenodesis of the autograft is performed to the lower trapezius tendon with a Pulvertaft technique. The shoulder is then immobilized in 40° to 60° of external rotation in a custom brace for 6 to 8 weeks. Passive and gradual active-assisted shoulder exercises should begin at 6 to 8 weeks postoperatively.

ALTERNATIVES

Surgical alternatives for irreparable tears include partial rotator cuff repair with biceps superior capsular reconstruction, superior capsular reconstruction with fascia lata graft, subacromial balloon spacer, and reverse shoulder arthroplasty. Tendon transfers are preferred in younger patients.

RATIONALE

The lower trapezius has adequate tension, a similar line of pull as the infraspinatus, and enough tension to replace the function of the infraspinatus. Biomechanical studies have shown that the maximum external rotation moment arm generated with use of a lower trapezius transfer with the arm at the side is superior to that with either latissimus dorsi or teres major transfer, and lower trapezius transfer is technically less cumbersome than other tendon transfer techniques.

EXPECTED OUTCOMES

Expected outcomes following the presently described procedure include significant improvements in pain and function. Elhassan et al. reported the outcomes of lower trapezius tendon transfer utilizing an allograft in 33 patients with an average age of 53 years (range, 31 to 66 years). At an average follow-up of 47 months, 32 patients had significant improvements in pain, SSV, and DASH score. One patient required debridement for an infection and later underwent shoulder arthrodesis. In a separate study, Elhassan et al. reported on 41 patients who underwent arthroscopically assisted lower trapezius transfer. Of these, 37 (90%) patients showed significant improvements in the VAS pain scale, SSV, and DASH scores. Two other patients with preoperative cuff arthropathy underwent reverse shoulder arthroplasty for persistent pain. The remaining 2 patients experienced a traumatic rupture, at 5 and 8 months postoperatively. Valenti and Werthel performed arthroscopically assisted lower trapezius transfer using hamstring graft in 14 patients with a mean age of 62 years (range, 50 to 70 years). Over a mean follow-up of 24 months (range, 12 to 36 months), the gain in external rotation was 24° with the arm at the side and 40° in 90° of abduction. Both the lag sign and hornblower sign were negative after this transfer. Two patients developed a hematoma, and a third patient underwent revision because of infection.

IMPORTANT TIPS

Proper case selection is necessary for optimal results.Ensure adequate release from the scapular spine to avoid difficult lower trapezius tendon harvesting and suboptimal lower trapezius tendon excursion.Utilize a combination of suture anchors to overcome insufficient graft fixation to the greater tuberosity as a result of poor bone stock.Make an adequate window beneath the infraspinatus fascia and utilize special long curved forceps to avoid difficult peroneus graft passage.Perform multiple cycles of rotation before fixation to avoid insufficient graft tensioning and graft excursion prior to lower trapezius attachment.

ACRONYMS AND ABBREVIATIONS

SSV = Shoulder Subjective ValueVAS = visual analog scaleDASH = Disabilities of the Arm, Shoulder and HandSST = Simple Shoulder TestERMA = external rotation moment armADL =activities of daily livingMRI= magnetic resonance imagingPEEK= polyetheretherketonePLT= peroneus longus tendon.

摘要

背景

巨大回缩性肩袖撕裂会使身体活跃的患者丧失劳动力。对于非手术治疗无效且持续疼痛的患者,有多种手术治疗选择。下斜方肌腱转移是一种很有前景的手术方法,可减轻疼痛、增强外旋力量并重建更正常的盂肱关节运动学。在本视频文章中,我们描述了使用易于获取的自体腓骨长肌腱进行成功的关节镜辅助下斜方肌转移术(SALTT)的手术技术。

描述

患者取沙滩椅位,同侧后肩胛带的一半纳入手术铺巾范围以便手术入路。通过标准的后方和后外侧入路观察关节,同时将前外侧和前上方入路用作操作入路。松解肩峰下和关节囊上部粘连,并进行部分肩袖修复。沿肩胛冈做一个3至4厘米的垂直切口。划定下斜方肌的上、下边界,并将其从肩胛冈的附着处完全游离。在外侧踝关节后缘做一个3厘米的垂直切口。切开筋膜。识别并在足最大背屈和外翻时将腓骨长肌游离,使用闭合式肌腱剥离器获取该肌腱。在自体移植物的一端放置套圈缝线。使用大抓钳,从前外侧入路开始,向肩胛内侧切口方向,将自体移植物穿梭过去,并用无结锚钉将自体移植物的缝线端固定于肱骨头。在肩部最大外旋且外展0°时,采用普尔弗塔夫技术将自体移植物与下斜方肌腱进行腱固定。然后将肩部用定制支具固定在外旋40°至60°位6至8周。术后6至8周应开始进行被动和逐渐主动辅助的肩部锻炼。

替代方法

不可修复撕裂的手术替代方法包括部分肩袖修复联合肱二头肌上关节囊重建、阔筋膜移植上关节囊重建、肩峰下球囊间隔器以及反肩置换术。肌腱转移术更适合年轻患者。

理论依据

下斜方肌具有足够的张力,其拉力线与冈下肌相似,且有足够的张力来替代冈下肌的功能。生物力学研究表明,使用下斜方肌转移术且手臂位于身体一侧时产生的最大外旋力矩臂优于背阔肌或大圆肌转移术,并且下斜方肌转移术在技术上比其他肌腱转移技术更简便。

预期结果

按照目前所描述的手术方法,预期结果包括疼痛和功能的显著改善。埃尔哈桑等人报告了33例平均年龄53岁(范围31至66岁)患者使用同种异体移植物进行下斜方肌腱转移术的结果。平均随访47个月时,32例患者的疼痛、肩部主观值(SSV)和上肢、肩部和手部功能障碍评分(DASH)均有显著改善。1例患者因感染需要清创,后来接受了肩关节融合术。在另一项研究中,埃尔哈桑等人报告了41例接受关节镜辅助下斜方肌转移术的患者。其中,37例(90%)患者的视觉模拟评分法(VAS)疼痛量表、SSV和DASH评分均有显著改善。另外2例术前存在肩袖关节病的患者因持续疼痛接受了反肩置换术。其余2例患者分别在术后5个月和8个月发生了创伤性撕裂。瓦伦蒂和韦瑟尔对14例平均年龄62岁(范围50至70岁)的患者使用绳肌腱移植物进行了关节镜辅助下斜方肌转移术。平均随访24个月(范围12至36个月)时,手臂位于身体一侧时外旋增加24°,外展90°时增加40°。转移术后滞后征和吹号角征均为阴性。2例患者出现血肿,第3例患者因感染接受了翻修手术。

重要提示

为获得最佳效果,需要进行适当的病例选择。确保从肩胛冈充分松解,以避免下斜方肌腱获取困难和下斜方肌腱活动度欠佳。联合使用缝合锚钉以克服因骨量不足导致移植物固定于大结节不充分的问题。在冈下肌筋膜下方制作足够大的窗口,并使用特殊的长弯钳以避免腓骨移植物通过困难。在固定前进行多次旋转循环,以避免移植物张力不足和在下斜方肌附着前移植物活动。

缩略词

SSV = 肩部主观值;VAS = 视觉模拟评分法;DASH = 上肢、肩部和手部功能障碍评分;SST = 简单肩部试验;ERMA = 外旋力矩臂;ADL = 日常生活活动;MRI = 磁共振成像;PEEK = 聚醚醚酮;PLT = 腓骨长肌腱

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本文引用的文献

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Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears.
J Shoulder Elbow Surg. 2020 Oct;29(10):2135-2142. doi: 10.1016/j.jse.2020.02.018. Epub 2020 Jun 9.
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