Zusammenfassung
Hintergrund
Eine fortgeschrittene RM-Ruptur mit Sehnenretraktion, fettiger Infiltration und Atrophie der RM-Muskulatur kann den Humerus im Glenohumeralgelenk nicht mehr suffizient zentrieren. Es entwickelt sich eine RM-Defektarthropathie als exzentrische Arthrose mit einer Azetabularisierung und einem Verbrauch des Akromions und des Glenoids.
Indikation
Bei schmerzhafter Pseudoparalyse des Arms ist die Implantation einer inversen Schulter-TEP (rTSA) zur Reduktion der Schmerzen und Wiederherstellung der aktiven Beweglichkeit indiziert. Die rTSA verbessert durch eine Medialisierung und Kaudalisierung des glenohumeralen Drehzentrums mit Optimierung des Hebelarms die motorische Aktivität des Deltamuskels. Gleichzeitig erhöht die rTSA die glenohumerale Stabilität und ist somit auch bei kraniokaudal zentrierten Omarthrosen mit statischer humeraler posteriorer Dezentrierung bei einem bikonkaven Glenoidverbrauch indiziert.
Therapie
Gegenwärtig zeigt die humerale anatomische Resektion von 135° Inklination und 20–40° Retrotorsion bei der rTSA im Vergleich zur ursprünglichen 155°-Inklination Vorteile in der Beweglichkeit ohne Defizite in der Stabilität. Zusätzlich sollte das Offset über eine knöcherne glenoidale Augmentation wiederhergestellt werden. Bei positivem Außenrotations-Lag-Zeichen aufgrund einer M.-infraspinatus/teres-minor-Insuffizienz verbessert eine M.-latissimus/teres-major-Sehnen-Ersatzplastik die aktive Außenrotation. Der M. subscapularis sollte beim deltopektoralen Zugang zugunsten der anterioren Stabilität bei der rTSA wenn möglich refixiert werden. Größere Glenosphären erhöhen die Stabilität und Beweglichkeit. Durch humerale metaphysäre Metallliner mit Polyethylen(PE)-Glenosphären können bei einem Anschlagen des humeralen Liners am inferioren Skapulahals Osteolysen durch fehlenden PE-Abrieb vermieden werden.
Abstract
Background
In a progredient rotator cuff tear with tendon retraction, fatty infiltration and atrophy of rotator cuff muscles the humerus cannot be centered and stabilized sufficiently in the glenohumeral joint. This leads to rotator cuff defect arthropathy as an eccentric osteoarthritis with acetabularization and wear of the acromion, as well as of the glenoid.
Indication
A painful pseudoparalysis of the shoulder indicates the implantation of a reversed total shoulder arthroplasty (rTSA) to reduce pain and restore active motion. The rTSA improves the motoric function of the deltoid muscle by medialization and caudalization of the center of rotation via an optimized lever arm and is also indicated in cranio-caudally centered osteoarthritis with static posterior humeral decentration due to a bi-concavely eroded glenoid.
Therapy
Currently, humeral anatomical resection with an inclination of 135° and a humeral retrotorsion of 20–40°, in rTSA in contrast to 155° inclination, has been shown to lead to better glenohumeral motion without loss of stability. Additionally, a reduced glenohumeral offset should be restored by especially bony lateral augmentation of the glenoid. In a pre-operatively positive lag sign for external rotation caused by a rupture of the infraspinatus/teres minor tendon, a lateral latissimus/teres major muscle tendon transfer in rTSA can optimize active external rotation. The tendon of the subscapularis muscle should be re-fixated in the deltopectoral approach for rTSA whenever possible for better anterior stability of the glenohumeral joint. Larger diameters of the glenospheres have been shown to have more stability and better motion. Humeral metaphyseal metal liners with corresponding polyethylene glenospheres can avoid osteolysis of the inferior scapular neck caused by polyethylene debris due to impingement of the humeral liner at the scapular neck.
Abbreviations
- AC-Gelenk:
-
Akromioklavikulargelenk
- LD:
-
M. latissimus major
- PE:
-
Polyethylen
- RM:
-
Rotatorenmanschette
- rTSA:
-
Inverse Schulter-TEP
- SSC:
-
M. subscapularis
- TEP:
-
Totalendoprothese
- TM:
-
M. teres major
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Patzer, T. Inverse Schultertotalendprothese bei Rotatorenmanschettendefektarthropathie. Orthopäde 47, 390–397 (2018). https://doi.org/10.1007/s00132-018-3543-6
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DOI: https://doi.org/10.1007/s00132-018-3543-6