Der Orthopäde

, Volume 47, Issue 2, pp 103–112 | Cite as

Joint-preserving treatment options for irreparable rotator cuff tears

Leitthema

Abstract

An irreparable cuff tear is defined as the inability to achieve direct repair of native tendon to the great tuberosity despite intra- and extra-articular release of the remaining tissue. Three distinct anatomic patterns are identified: posterosuperior cuff tears which involve the supraspinatus, infraspinatus and teres minor; anterosuperior tears which involve the supraspinatus and subscapularis; and global tears which comprise both. Subacromial debridement and tenotomy or tenodesis of the long head of the biceps are proposed for older patients with a functional but very painful shoulder. Partial repair—particularly the infraspinatus and the subscapularis—is indicated for young patients if the muscle is still trophic with a fatty infiltration less than 3. It can be combined with a tendon transfer. In irreparable posterosuperior tears, latissimus dorsi or lower trapezius transfer has been reported to improve active elevation and external rotation. In anterosuperior cuff tears, pectoralis major or latissimus transfer has been used. If the lack of external rotation is isolated with good active forward elevation, the L’Episcopo procedure is the procedure of choice. New techniques with a short follow-up have been proposed recently: implantation of a balloon-shaped, biodegradable spacer in the subacromial space to maintain the position of the humeral head and to facilitate deltoid action; capsular superior reconstruction with a fascia lata or an artificial graft implanted between the superior glenoid rim and the great tuberosity to reproduce the natural capsule of the supra- and infraspinatus and to stabilize the humeral head.

Keywords

Subacromial debridement Tenotomy Episcopo procedure Subacromial balloon-shaped spacer Tenodesis 

Abbreviations

ASCR

Arthroscopic superior capsular reconstruction

ASES score

American Shoulder and Elbow Surgeons score

CT

Computed tomography

LD

Latissimus dorsi

LDT

Latissimus dorsi transfer

MRI

Magnetic resonance imaging

SST

Simple shoulder test

SSV

Shoulder subjective value

UCLA

University of California Los Angeles

Gelenkerhaltende Behandlungsoptionen bei irreparablen Rotatorenmanschettenrupturen

Zusammenfassung

Eine irreparable Rotatorenmanschettenruptur ist definiert durch die fehlende Möglichkeit, eine direkte Refixation der nativen Sehne am Tuberculum majus zu erreichen trotz einer intra- und extraartikulären Freisetzung des verbleibenden Gewebes. Drei unterschiedliche anatomische Muster wurden identifiziert: posterosuperiore Rotatorenmanschettenrupturen unter Beteiligung von Supraspinatus, Infraspinatus und Teres minor; anterosuperiore Rupturen unter Beteiligung von Supraspinatus und Subscapularis sowie umfassende Rupturen unter Beteiligung aller genannten Strukturen. Ein subakromiales Débridement und eine Tenotomie oder Tenodese der langen Bizepssehne werden bei älteren Patienten mit funktionsfähiger, aber sehr schmerzhafter Schulter vorgeschlagen. Eine Teilrekonstruktion – insbesondere Infraspinatus und Subscapularis – ist bei jungen Patienten indiziert, wenn der Muskel noch trophisch ist und eine Fettinfiltration unter 3 vorliegt. Die Teilrekonstruktion ist mit einem Sehnentransfer kombinierbar. Bei irreparablen posterosuperioren Rupturen wurde berichtet, dass ein Latissimus-dorsi-Transfer oder der Transfer des unteren Trapezius die aktive Elevation und Außenrotation verbessert. Bei anterosuperioren Rotatorenmanschettenrupturen wurde ein Pectoralis-major- oder Latissimus-Transfer angewendet. Liegt eine fehlende Außenrotation isoliert bei guter aktiver Anteversion vor, ist das L’Episcopo-Verfahren die Methode der Wahl. Neue Verfahren mit einem kurzen Follow-up wurden in jüngerer Zeit vorgeschlagen: Implantation eines ballonförmigen, biologisch abbaubaren Spacers in den subakromialen Raum zur Erhaltung der Position des Humeruskopfs und zur Erleichterung der Deltoideusfunktion; Rekonstruktion der oberen Gelenkkapsel mit einem Fascia-lata- oder einem künstlichen Graft implantiert zwischen den oberen Glenoidrand und das Tuberculum majus, um die natürliche Kapsel des Supra- und Infraspinatus nachzubilden und den Humeruskopf zu stabilisieren.

Schlüsselwörter

Subakromiales Débridement Tenotomie L’Episcopo-Verfahren Subakromialer ballonförmiger Spacer Tenodese 

Notes

Compliance with ethical guidelines

Conflict of interest

P. Valenti declares that he has no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Paris Shoulder UnitClinique BizetParisFrance

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