Latissimus Dorsi Transfer Results Endure Over Time: Commentary on an article by Christian Gerber, MD, FRCSEd(Hon), et al.: “Latissimus Dorsi Tendon Transfer for Treatment of Irreparable Posterosuperior Rotator Cuff Tears. Long-Term Results at ...

第一作者：Guido Marra

2013-11-21 点击量：599 　　我要说

Latissimus Dorsi Transfer Results Endure Over Time: Commentary on an article by Christian Gerber, MD, FRCSEd(Hon), et al.: “Latissimus Dorsi Tendon Transfer for Treatment of Irreparable Posterosuperior Rotator Cuff Tears. Long-Term Results at a Minimum Follow-up of Ten Years”

Over the last decade, a wealth of clinical experience with reverse shoulder arthroplasty has been published. The introduction of the reverse arthroplasty has had a major impact on the management of the rotator-cuff-deficient shoulder. However, reverse shoulder arthroplasty has demonstrated all of the drawbacks inherent in any artificial joint replacement, including durability. Patients with rotator cuff insufficiency have diverse presentations, and such insufficiency presents a unique challenge in young, higher-demand patients who are not ideal candidates for reverse arthroplasty. Since its initial presentation in 1988, latissimus dorsi transfer has gained wide acceptance for the management of such patients with irreparable rotator cuff tears. Longer-term follow-up studies such as this one by Gerber et al. are critical to our understanding of the role of latissimus dorsi transfer in this population, in terms of both clinical longevity and the effect of the transfer on the glenohumeral articulation.

The original series presented in 1988¹ and the follow-up study in 1992² helped define the clinical indications for this procedure, and those indications are reflected in the present study’s inclusion criteria. The present series demonstrates the long-term clinical effectiveness of latissimus dorsi transfer in a well-defined subset of patients with posterosuperior rotator cuff insufficiency. The clinical results achieved in the present series are comparable with those previously published with respect to improvement of shoulder motion and patient satisfaction. Importantly, these results at intermediate and long-term follow-up in the present study did not show appreciable deterioration over time.

The association of rotator cuff tears with subsequent glenohumeral joint degeneration has been systematically evaluated by many authors. Several classification systems have been proposed and have demonstrated progression of arthropathic changes in the glenohumeral joint in the presence of large defects in the rotator cuff. In the present series, the mean stage of osteoarthritis as classified by Samilson and Prieto³ progressed by 0.6 stages over the twelve-year follow-up period. Using the same classification in an evaluation of nineteen patients with a mean age of sixty-four years who had chronic tears of the rotator cuff, Zingg et al. demonstrated a mean progression of 1.1 stages at four years of follow-up⁴. This demonstrates that, although latissimus dorsi transfer does not prevent degeneration of the glenohumeral joint in the presence of a massive rotator cuff defect, it does appear to slow the progression of joint degeneration compared with that in patients undergoing no treatment. This has important implications when considering treatment options for the younger, high-demand patients who are the target population for this procedure.

Many patients who are considered candidates for this procedure have had prior failed operative attempts at surgical reconstruction of the rotator cuff defect. In the present series, the proportion of revision procedures in the group with an unsatisfactory result was greater than that in the group with a satisfactory result, but this difference did not reach significance (p = 0.09). The literature remains confusing regarding the results of latissimus dorsi transfer in the setting of revision repair. Buchmann et al. reported no difference in clinical results when comparing latissimus dorsi transfer in primary and revision cases in a retrospective matched-pair study with twenty months of follow-up⁵. This is in contrast to the experience of Warner and Parsons, who found a mean Constant score of 55% in the revision setting compared with 70% in primary procedures (p < 0.05) at nineteen months of follow-up⁶. Surgeons contemplating the use of latissimus dorsi transfer in the revision setting must carefully consider the strict inclusion and exclusion criteria presented in each of these studies.

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