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Rezidivinstabilität und Instabilitätsarthropathie

Recurrent instability and instability arthropathy

Zusammenfassung

Bei anteroinferiorer Schulterinstabilität wird bei jungen, funktionell anspruchsvollen Patienten mit isolierter Weichteilverletzung aufgrund der hohen Reluxationsneigung die Kapsel-Labrum-Rekonstruktion (Bankart-Repair) empfohlen, welche sich etabliert hat und sowohl für das offene wie auch das arthroskopische Vorgehen mit guten klinischen Ergebnissen belegt ist. Nichtsdestotrotz werden Luxationsraten von bis zu 25 % beobachtet. Verantwortlich hierfür sind neben risikobereiten Patienten (Kontaktsportarten), häufig ein primär unterschätzter glenoidaler Knochenverlust, nicht adressierte bipolare Defekte oder eine technisch fehlgeschlagene Erstoperation.

Im Management der Rezidivinstabilität bedarf es neben der erweiterten Diagnostik mit Röntgen und Computertomographie v. a. einer ausführlichen klinischen Untersuchung des Patienten. Ein erneuter Bankart-Repair ist in seltenen ausgewählten Fällen indiziert. Häufiger zeigen sich jedoch therapiebedürftige knöcherne Defekte an Glenoid oder Humeruskopf (Hill-Sachs-Läsion), welche durch knochenaufbauende Verfahren zu adressieren sind. Biomechanisch vorteilig präsentiert sich die Operation nach Latarjet durch den sog. „Sling-Effekt“ der „conjoined tendons“ gegenüber Span- und Knochenblockverfahren. Ein Konsensus bzgl. der Therapie von Hill-Sachs-Läsionen besteht derzeit nicht. Bei großen, weit medial gelegenen Defekten stehen neben der Weichteilinterposition („remplissage“) der Infraspinatussehne Knochenblockverfahren und der partielle Oberflächenersatz zur Verfügung.

Als Folge häufiger (Re)-Luxationen ist die Instabilitätsarthropathie eine oft unterschätzte Komplikation. Hierbei steht nicht die Instabilität, sondern eine schmerzhafte Bewegungseinschränkung im Vordergrund. Die arthroskopische Arthrolyse oder das „comprehensive arthroscopic management“ (CAM-Procedure) können hierbei als gelenkerhaltende Maßnahmen zur Verbesserung der Lebensqualität beitragen.

Abstract

Capsulolabral reconstruction (Bankart repair) is recommended as the first line treatment in young and functionally demanding active patients with anteroinferior shoulder instability, due to the high tendency to recurrent dislocation. This has become established both for arthroscopic and open primary shoulder stabilization with good clinical outcome; nevertheless, recurrence of dislocation is reported in up to 25% of patients. Risk factors for failed surgery are patient (e.g. young age, male gender and contact sports) and surgery (e.g. primarily underestimated glenoid bone loss, Hill-Sachs lesion, non-treatment of bipolar defects or malpositioned anchors) related. In the management of recurrent instability, it is necessary to carry out a thorough clinical investigation in addition to extended diagnostics with X‑ray and computed tomography. A second Bankart repair is only indicated in patients with low demands and without any glenoid bone loss. In the majority of patients, bony augmentation of the glenoid is necessary and realized by coracoid or iliac crest bone block transfer. The Latarjet procedure is biomechanically advantageous due to the additional sling effect of the conjoined tendons and both techniques show good clinical outcomes and a low recurrence rate. Furthermore, engaging Hill-Sachs lesions also require additional treatment. Remplissage of the infraspinatus muscle, iliac crest bone block transfer and partial joint replacement are viable options. A final consensus for treatment of Hill-Sachs lesions has yet to be defined. Dislocation arthropathy is an underestimated complication as a result of frequent recurrent dislocations. After development of dislocation arthropathy, patients reported a painful restriction of range of motion rather than instability. Arthroscopic arthrolysis and comprehensive arthroscopic management (CAM procedure) are possible joint-preserving treatment options.

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Interessenkonflikt

L. Lacheta, S. Siebenlist, A.B. Imhoff und L. Willinger geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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B. Ockert, München

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Lacheta, L., Siebenlist, S., Imhoff, A.B. et al. Rezidivinstabilität und Instabilitätsarthropathie. Unfallchirurg 121, 142–151 (2018). https://doi.org/10.1007/s00113-017-0408-0

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  • DOI: https://doi.org/10.1007/s00113-017-0408-0

Schlüsselwörter

  • Schulter
  • Bankart-Repair
  • Latarjet
  • Beckenkammspan
  • Hill-Sachs-Defekt

Keywords

  • Shoulder
  • Bankart repair
  • Latarjet
  • Iliac crest bone block
  • Hill-Sachs defect