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Latissimus-dorsi-Transfer bei irreparablen posterior-superioren Rotatorenmanschettendefekten bei älteren Patienten

Mittelfristige Ergebnisse

Transfer of latissimus dorsi muscle for irreparable posterosuperior rotator cuff defects in older patients

Medium term results

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Zusammenfassung

Zielsetzung

Ist der Latissimus-dorsi-Transfer (LDT) auch bei älteren Patienten bei chronischen posterior-superioren Rotatorenmanschettendefekten eine gute Option?

Material und Methode

In den Jahren 2010–2016 wurden 25 Patienten ohne glenohumerale Arthrose und nichtrekonstruierbare Supra- und Infraspinatussehne bei noch zentrierbarem Glenohumeralgelenk und einer erhaltenen Restfunktion der Anteversion bei irreparablen posterior-superioren Rotatorenmanschettendefekten mittels LDT am KH Rummelsberg (Sana) operiert. Neun Patienten (36 %) hatten eine oder mehrere Rekonstruktionsversuche der Rotatorenmanschette in der Vorgeschichte. Alle anderen Patienten (64 %), mit einem Durchschnittsalter von 61 Jahren, wurden einer primären Rekonstruktion mittels LDT zugeführt. Es konnten 24 von 25 Patienten (96 %), bei einem durchschnittlichen Follow-up von 32 Monaten, klinisch anhand des Constant-Score (CS) und der visuellen Analogskala (VAS) nachuntersucht werden. Die Operation erfolgte in der von Gerber beschriebenen Technik zur Hebung des Latissimus dorsi, allerdings in „Beach-chair“-Position. Die Nachbehandlung erfolgte für 6 Wochen in der ACRO-Assist-Schiene (Schulterorthese) in 90°-Abduktion unter täglicher limitierter Außenrotationsbeübung mit anschließender ambulanter Rehabilitation.

Ergebnisse

Die durchschnittliche Operationszeit betrug 112 min (68–199 min). Die einzige Komplikation bestand in einer festgenähten Redon-Drainage. Der präoperative Constant-Wert betrug im Mittel 25 Punkte, der postoperative Constant-Wert 60 Punkte bei einem mittleren Zugewinn von 35 Punkten. Der alterskorrigierte relative Constant-Score lag postoperativ bei 74. Die Schmerzwahrnehmung verbesserte sich hochsignifikant von präoperativen starken bis sehr starken Schmerzen auf postoperativ geringe bis keine Schmerzen. Im VAS-Score gab es eine Reduktion von präoperativ 6 auf postoperativ 3 VAS-Punkte. Die Außenrotation verbesserte sich im Mittel von 3 Punkten auf 6 Punkte im CS.

Der präoperative Constant-Wert bei Patienten <60 Jahre (n = 12) betrug 20, der postoperative Constant-Wert 51, bei einem Zugewinn von 31 Constant-Punkten. Bei Patienten ≥60 Jahre (n = 12) betrug der präoperative Constant-Wert 31, der postoperative Constant-Wert 60 Punkte. Der Zugewinn beträgt 29 Punkte. Der Unterschied zwischen den Altersgruppen ist nicht signifikant.

Die voroperierten Patienten (arthroskopische oder offene Rotatorenmanschettenrekonstruktion) zeigten zwar eine gute Verbesserung des Constant-Werts (um 26 gegenüber 32 Punkten bei nichtvoroperierten Patienten), allerdings auf niedrigerem Niveau im Constant-Wert (45 vs. 69 Punkte).

Schlussfolgerung

Bei geeigneter Patientenselektion kann auch im hohen Patientenalter mit dem LDT ein hoher Zugewinn im CS erreicht werden. Der VAS-Score und die Außenrotation verbessern sich signifikant. Voroperationen beeinträchtigen das Ergebnis.

Abstract

Objective

Is transfer of the latissimus dorsi muscle (LDT) a good option in older patients with irreparable posterosuperior rotator cuff tears?

Material and method

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.

Results

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).

Conclusion

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.

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Authors and Affiliations

  1. Klinik für Unfall‑, Schulter- und Wiederherstellungschirurgie, Sportmedizin und Sporttraumatologie, Sana Krankenhaus Rummelsberg, Rummelsberg 71, 90592, Schwarzenbruck, Deutschland

    S. Ebert-Fillmer, U. T. Bloos, S. El Masri & R. Stangl

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Correspondence to S. Ebert-Fillmer.

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S. Ebert-Fillmer, U.T. Bloos, S. El Masri und R. Stangl geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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113_2018_557_MOESM1_ESM.pdf

Eigene Patienten (nach Alter sortiert). FU Follow-up, CS Constant, VAS visuelle Analogskala, Aro Außenrotationspunktwert im Constant-Wert

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Ebert-Fillmer, S., Bloos, U.T., El Masri, S. et al. Latissimus-dorsi-Transfer bei irreparablen posterior-superioren Rotatorenmanschettendefekten bei älteren Patienten. Unfallchirurg 122, 544–554 (2019). https://doi.org/10.1007/s00113-018-0557-9

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