Free coracoacromial ligament graft for augmentation of massive rotator cuff tears treated with mini-open repair

Amaç: Masif rotator manşet yırtıklarının tamiri karmaşık ve zahmetlidir. Yırtıklar genellikle eski ve dejenere olduğu için uçları genellikle zayıf ve tekrar yırtılmaya müsaittir. iyi sonuçlara ulaşabilmek için uç dikişleri sağlam ve dayanıklı olmalıdır. Rotator manşet yırtıklarında tamiri korumak ve desteklemek için serbest olarak tam veya kısmi korakoakromiyal bağ (KAB) kullanı- mının etkinliğini değerlendirmeyi amaçladık. Çalışma planı: Ocak 2003 ve Haziran 2009 tarihleri arasında masif rotator manşet yırtığına mini- açık tamir uygulanan 46 hasta [42 kadın, yaş ortalaması 54.3 (dağılım 39-66)] çalışmaya dahil edildi. Hastalar›n 29’unda sağ ve 17’sinde sol tarafta yırtık mevcuttu. Yırtıkların 15’i 3-4 cm (ortalama 3.5 cm), 27’i >4 cm (ortalama 4.5 cm) ve 4’ü >5 cm genişliğinde idi. Ortalama takip süresi 26 ay (dağılım 16-52 ay) idi. Primer tamir sonrası hastaların 18’ine tam, 28’ine kısmi serbest KAB grefti kullanılarak rekonstrüksiyon uygulandı. Hastalar Constant-Murley skoru ve aktif fleksiyon ve abduksiyon derecelerine göre de¤erlendirildi. Takiplerde ultrasonografi ile tendon kalınlığı ölçüldü. Sonuçlar: Ortalama ameliyat öncesi omuz fleksiyonu 27.5° (dağılım 5-40°), abduksiyonu 22.5° (dağılım 10-30°) olarak bulundu. Ameliyat sonrası ortalama fleksiyon, anlamlı artış kaydedilerek 102.6° (dağılım 70-150°), abduksiyon ise 96.5° (dağılım 60-150°) olarak bulunmuştur. Ameliyat öncesi ortalama Constant-Murley skoru 45 iken, ameliyat sonrası 80 olarak kaydedilmiştir. Ameliyat sonrası dönemde ve takiplerde hiçbir cerrahi komplikasyon, özellikle tekrar yırtık gelişmemiştir. Son kontrollerde tendon kalınlıkları ve bütünlükleri normal tendon ile aynı bulunmuştur. Çıkarımlar: Açık-mini tamir ile onarılan masif rotator manflet yırtıklarının serbest KAB grefti ile desteklenmesi sonucunda mükemmel ve umut verici sonuçlar elde edilebilir.

Mini-açık tamir tekniği ile tedavi edilen masif rotator manflet yırtıklarının serbest korakoakromiyal bağ grefti ile desteklenmesi

Objectives: Repair of massive rotator cuff tears is a challenging and complex procedure. The tissue at the end of the torn tendons is often friable and weak, because ruptures are old and degenerated, and thus the ends must be sutured effectively and strongly to achieve a satisfactory outcome. We aimed to evaluate the effectiveness of free total or partial coracoacromial ligament (CAL) graft to protect and augment the repair of massive rotator cuff tears. Methods: Forty six patients ((32 females, mean age 54.3 years (range 39-66 years)) operated for massive rotator cuff tears between January 2003 and June 2009 were included in the study. Twenty nine of these patients had right-sided tears, and 17 had left-sided tears. Fifteen of the tears were 3-4 cm wide (mean 3.5 cm); 27 were >4 cm wide (mean 4.5 cm), and 4 were >5 cm wide. The mean follow-up period was 26 months (range 16-52 months). Patients were operated with a mini-open technique, and reconstructed after primary repair with 18 total and 28 partial free transfer of the CAL. Patients were evaluated by Constant-Murley score, and the degree of active flexion and abduction. Tendon thickness was measured with ultrasonography during follow-up. Results: Mean preoperative shoulder flexion was 27.5° (range 5-40°), and mean abduction was 22.5° (range 10-30°). Shoulder flexion was significantly greater postoperatively (mean 102.6°, range 70-150°), as was shoulder abduction (mean 96.5°, range 60-150°). Mean preoperative and postoperative Constant-Murley score was 45 and 80, respectively. Surgical complications, particularly recurrence, did not occur in any patient during the follow-up period. The integrity and tendon thickness of the repairs were similar to those of normal tendons at the end of follow-up. Conclusion: Augmentation with a free transfer of the coracoacromial ligament provides excellent and promising functional results in the operative treatment of massive rotator cuff tears with a mini-open technique

___

1. Bezer M, Kocao¤lu B, Erol B, Ayd›n N, Güven O. Longterm results of open surgical repair of rotator cuff tears. [Article in Turkish] Acta Orthop Traumatol Turc 2004;38:110-4.
2. Ben Maitigue M, Bouaouaja G, Ben Chaabane T, Khezami M, Sehimi N, Kchalfi S, et al. Results of deltoid flap for the surgery of rotator cuff tears. [Article in French] Tunis Med 2008;86:1066-9.
3. Hadjicostas PT, Soucacos PN, Theissen M, Thielemann FW. The use of split deltoid-flap in the treatment of massive rotator cuff defects: a retrospective study of 61 patients. Knee Surg Sports Traumatol Arthrosc 2008;16:876-83.
4. Lu XW, Verborgt O, Gazielly DF. Long-term outcomes after deltoid muscular flap transfer for irreparable rotator cuff tears. J Shoulder Elbow Surg 2008;17:732-7.
5. Birmingham PM, Neviaser RJ. Outcome of latissimus dorsi transfer as a salvage procedure for failed rotator cuff repair with loss of elevation. J Shoulder Elbow Surg 2008;17:871-4.
6. Gavriilidis I, Kircher J, Magosch P, Lichtenberg S, Habermeyer P. Pectoralis major transfer for the treatmentof irreparable anterosuperior rotator cuff tears. Int Orthop 2010;34:689-94.
7. Nové-Josserand L, Costa P, Liotard JP, Safar JF, Walch G, Zilber S. Results of latissimus dorsi tendon transfer for irreparable cuff tears. Orthop Traumatol Surg Res 2009;95:108-13.
8. Sloan SM, Budoff JE, Hipp JA, Nguyen L. Coracoclavicular ligament reconstruction using the lateral half of the conjoined tendon. J Shoulder Elbow Surg 2004;13:186-90.
9. Kesmezacar H, Akgün I, Ö¤üt T, Gökay S, Uzun I. The coracoacromial ligament: the morphology and relation to rotator cuff pathology. J Shoulder Elbow Surg 2008;17:182-8.
10. Moorman CT 3rd, Hussain SS, Warren RF, Deng XH, Wickiewicz TL, Torzilli PA. Anatomy of the coracoacromial veil. J Surg Orthop Adv 2008;17:69-73.
11. Demirhan M, Atalar AC, Kocabey Y, Akal›n Y. Arthroscopic assisted mini-open rotator cuff repair. [Article in Turkish] Acta Orthop Traumatol Turc 2002; 36:1-6.
12. Ekin A, Özcan C. Massive rotator cuff tears: diagnosis and treatment techniques. [Article in Turkish] Acta Orthop Traumatol Turc 2003;37:87-92.
13. Wellmann M, Petersen W, Zantop T, Schanz S, Raschke MJ, Hurschler C. Effect of coracoacromial ligament resection on glenohumeral stability under active muscle loading in an in vitro model. Arthroscopy 2008;24:1258-64.
14. Su WR, Budoff JE, Luo ZP. The effect of coracoacromial ligament excision and acromioplasty on superior and anterosuperior glenohumeral stability. Arthroscopy 2009;25:13-8.
15. Hansen U, Levy O, Even T, Copeland SA. Mechanical properties of regenerated coracoacromial ligament after subacromial decompression. J Shoulder Elbow Surg 2004;13:51-6.
16. Levy O, Copeland SA. Regeneration of coracoacromial ligament after acromioplasty and arthroscopic subacromial decompression. J Shoulder Elbow Surg 2001;10:317-20.
17. Bak K, Spring BJ, Henderson IJ. Re-formation of the coracoacromial ligament after open resection or arthroscopic release. J Shoulder Elbow Surg 2000;9:289-93.