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肩関節・肘関節・手関節・股関節・膝関節・足関節・腰背部の術後療法や保存療法、スポーツ障害に対するリハビリテーションを行なっています。
すべては患者さんの笑顔のために」 All for a smile of patient... by OH!NO!DX

修復不能な前上方腱板断裂に対する大胸筋腱移行術の長期治療成績

Long-Term Outcome After Pectoralis Major Transfer for Irreparable Anterosuperior Rotator Cuff Tears
Moroder, Philipp MD; Schulz, Eva; Mitterer, Marian MD; Plachel, Fabian MD; Resch, Herbert MD; Lederer, Stefan MD
Journal of Bone & Joint Surgery - American Volume:  1 February 2017 - Volume 99 - Issue 3 - p 239–245 [原文]  [手術説明動画]

Fig. 1. Figs. 1-A through 1-F The surgical technique for the pectoralis major tendon transfer.
 Fig. 1-A The patient is placed in the supine position with the upper body upright at a 30° angle. A deltopectoral approach is used to expose the humeral head in the left shoulder, and the extent and reparability of the anterosuperior cuff tear is evaluated.
 Fig. 1-B If the long head of the biceps tendon is still intact, a tenotomy is performed. Often the tendon is dislocated and can be found medial to the sulcus. The tendon insertion of the pectoralis muscle and the adjacent lateral part of the muscle are exposed. The inferior edge of the muscle is freed from surrounding soft tissue in order to allow the index finger to pass underneath the muscle from the inferior direction.
Fig. 1-C A blunt Hohmann retractor, instead of the finger, is then inserted from inferomedially underneath the pectoralis major muscle toward the proximal humeral shaft, giving access to the backside of the tendon. With a 10-mm chisel, the osseous insertion of the tendon is subperiostally detached.
Fig. 1-D Then the Hohmann retractor is removed, and the same procedure is performed on the anterior side of the tendon.
Fig. 1-E In a shoulder with an isolated subscapularis tendon tear, only the upper half of the tendon is harvested, while in a shoulder with a concomitant supraspinatus tendon tear, the upper two-thirds of the tendon is harvested. In doing so, mostly the abdominal and sternocostal portions of the pectoralis major muscle are harvested because of the twisted tendon insertion. The detached part of the tendon is then secured with stay sutures around the included bone chip, and the pertinent part of the pectoralis muscle is divided from the remainder of the muscle by blunt dissection for a length of approximately 8 cm.
 Fig. 1-F The space between the conjoined tendon and the pectoralis minor tendon is carefully dissected, exposing the musculocutaneous nerve. If the distance between the coracoid and the entrance of the musculocutaneous nerve into the muscle is short, the nerve is freed by blunt dissection in order to create space for the muscle transfer. The index finger is used to create a passage underneath the conjoined tendon, and the detached portion of the pectoralis muscle is pulled through the opening. Caution must be taken to avoid tensioning and interposition of the musculocutaneous nerve. After creation of a shallow trough at the planned insertion site, the transferred tendon is fixed using transosseous sutures or suture anchors. If an isolated rupture of the subscapularis is treated, the transferred tendon is attached to the lesser tuberosity. However, in the case of concomitant involvement of the supraspinatus, the transferred tendon is attached slightly more superolaterally to cover part of the anterior aspect of the greater tuberosity. No attempt is made to close the gap to the infraspinatus tendon.

Postoperatively, patients are managed with immobilization in a sling and passive mobilization with limited external rotation to 0°, abduction to 60°, and flexion to 90° for 4 weeks. After 4 weeks, active-assisted motion is started, followed by active motion with free range of motion after 6 weeks, except for external rotation, which remains limited for 8 weeks. Strength exercises are started 3 months after surgery.
Moroderらは、修復不能な肩腱板広範囲断裂(前上方腱板断裂)で大胸筋腱移行術を施行した患者22例を対象に、術後の長期転帰を報告している。

疼痛(VAS pain)は術後5年の短期成績と比較して術後10年の長期成績では有意に改善している(P=0.001)。Simple Shoulder Test の疼痛項目は術前7点から術後5年で10点(P = 0.004)、術後10年で9点と改善し、術後5年と術後10年では疼痛項目の改善に有意差はなかった(P=0.303)。


ROMは術前と比較して有意に改善し(P=0.029)、特に内旋が改善した(P<0.001)。最終調査時の平均ROMは、外転137° ± 32° 、屈曲133° ± 35°、外旋47° ± 15° 、内旋は第1腰椎棘突起 (±3 levels)であった。


調整後のConstant Scoreは術前の54%から短期追跡評価時に87%に有意に増加したとし(P<0.001)、長期追跡期間の10年時でも83%と有意に高値が維持されたと報告している(P=0.001)。


長期追跡評価時における患者満足度も77%と高く、追跡終了時までに報告された再手術(リバース型人工肩関節置換術)は1例(5%)のみだった。


日本にもリバース型人工肩関節置換術が導入されて2年が経過したこともあり、一次修復不能な腱板断裂においては"リバース"が選択されることも少なくないが、本法やパッチ法、上方関節包修復、Debyre-Patte変法、広背筋腱移行など様々な修復術が存在し、現在も工夫が続いている。あくまでも"リバース"が最終手段である以上、これらの修復術に対応した術後運動療法が求められることになる。理学療法士として研鑽を重ねていきたい。


All for a smile of patient... by OH!NO!DX