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Instabilität des Glenohumeralgelenks

Pathomechanismen, Klassifikation und Therapieprinzipien

Instability of the glenohumeral joint

Pathomechanisms, classification and therapeutic principles

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Zusammenfassung

Das primär wenig stabile Glenohumeralgelenk wird durch ein feines Zusammenspiel von aktiven und passiven Elementen stabilisiert. Nur dadurch wird die schmerzfreie harmonische und kraftvolle Bewegung in allen 3 Ebenen ermöglicht. Neben den rein funktionellen Störungen dieses Zusammenspiels sind strukturelle Schäden häufige Ursachen für Instabilitätssymptome und Luxationen. Die Klassifikation anhand der Richtung, des Vorliegens eines Traumas und einer Hyperlaxität ist etabliert.

Neben der sorgfältigen Anamnese und gezielten klinischen Untersuchung mit speziellen Stabilitätstests stellt die bildgebende Diagnostik die Weichen für die Therapie. Mithilfe von Standardröntgenaufnahmen können knöcherne Läsionen erkannt und verhakte Luxationen ausgeschlossen werden. Die Sonographie liefert einen Zustandsbericht zur Rotatorenmanschette (RM); Magnetresonanztomographie (MRT) und Computertomographie (CT) beschreiben die strukturellen Schäden im Glenohumeralgelenk.

Die Entscheidung zur operativen Therapie erfolgt mit Blick auf Lebensalter, Sportniveau, Beruf, Risikoprofil und Anspruch des Patienten sowie auf den vorliegenden Strukturschaden. Größere knöcherne Pfannenläsionen können nicht kompensiert werden und gelten als dringliche Operationsindikation. Fehlende Strukturschäden und ausgeprägte funktionelle Störungen der skapulohumeralen Balance (oftmals mit multidirektionaler Instabilität) sind die Domäne der konservativen Therapie.

Die operative Therapie hat das Ziel der anatomischen Rekonstruktion; dieses kann klassisch offen oder arthroskopisch erreicht werden. Beide Verfahren haben spezielle Vor- und Nachteile.

Mit modernen Therapieverfahren sind bei Beachtung der Indikationsstellung niedrige Rezidivraten, eine hohe Rate an Rückkehr in Sport und Beruf sowie eine verbesserte Langzeitprognose im Hinblick auf die Entwicklung der Instabilitätsarthrose zu erwarten.

Abstract

The force-fit glenohumeral joint is stabilized by a fine interaction of passive and active stabilizers. Only in this way is a painless harmonious and powerful movement in all directions feasible. Besides the genuine functional disorders of this interplay, structural lesions are common causes of instability symptoms and dislocations. The classification based on the direction of instability, the trauma history and the presence of hyperlaxity is commonly accepted.

Alongside the thorough history of present complaints and skilful clinical examination including special instability test maneuvers, diagnostic imaging sets the course for therapeutic interventions. Ultrasound gives a status report about the rotator cuff whereas magnetic resonance imaging (MRI) and computed tomography (CT) illustrate the structural damage to the glenohumeral joint.

A decision for operative therapy is based on patient age, sport level, profession, risk profile, personal requirements of the patient and the present structural lesions. Major bony glenoid lesions cannot be compensated and are considered an urgent indication for surgery. The absence of structural disorders and pronounced functional deficits of scapulo-humeral balance (often accompanied by multidirectional instability) is the domain of conservative treatment.

Surgical therapy aims at anatomical reconstruction which can be achieved both with classic open and arthroscopic techniques whereas both have advantages and disadvantages.

Based on careful consideration of the indications, modern therapeutic interventions can achieve a low risk of recurrence, high rates of return to sport and profession and improved future prospects regarding instability arthropathy in the long-term can be expected.

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Literatur

  1. Akhtar MA, Robinson CM (2010) Generalised ligament laxity and shoulder dislocations after sports injuries. Br J Sports Med 44:Electronic pages: i3. DOI 10.1136 bjsm.2010.07872.9

  2. Arciero RA, Wheeler JH, Ryan JB, McBride JT (1994) Arthroscopic Bankart repair versus nonoperative treatment for acute inital anterior shoulder dislocation. Am J Sports Med 22:589–594

    Article  CAS  PubMed  Google Scholar 

  3. Balg F, Boileau P (2007) The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg 89-B:1470–1477

    Article  Google Scholar 

  4. Beighton P, Solomon L, Soskolne CL (1973) Articular mobility in an African population. Ann Rheum Dis 32:413–418

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  5. Bertelli JA, Ghizone ME (2011) Abduction in internal rotation: a test for the diagnosis of axillary nerve palsy. J Hand Surg Am 36:2017–2023

    Article  PubMed  Google Scholar 

  6. Bigliani LU, Newton PM, Steinmann SP, Connor PM, McIlveen S (1998) Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med 26:41–45

    CAS  PubMed  Google Scholar 

  7. Blasier RB, Carpenter JE, Huston LJ (1994) Shoulder proprioception. Effect of joint laxity, joint position and direction of motion. Orthop Rev 23:45–50

    CAS  PubMed  Google Scholar 

  8. Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L (2006) Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg 88-A:1755–1763

    Article  Google Scholar 

  9. Bonnevialle N, Mansat P, Bellumore Y, Bonnevialle P (2008) Traitement chirurgical des instabilités antérieures de l’épaule chez les joueurs de rugby: résultats cliniques et radiographiques au recul minimum de cinq ans. Rev Chir Orthop Reparatrice Appar Mot 94:635–642

    Article  CAS  PubMed  Google Scholar 

  10. Cameron KL, Duffey ML, DeBerardino RM, Stoneman PD, Jones CJ, Owens BD (2010) Association of generalized joint hypermobility with a history of glenohumeral joint instability. J Athl Train 45:253–258

  11. Castagna A, Markopulos N, Conti M, Delle Rose G, Papadakou E, Garofalo R (2010) Arthroscopic Bankart suture-anchor repair: radiological and clinical outcome at minimum 10 years of follow-up. Am J Sports Med 38:2012–2016

    Article  PubMed  Google Scholar 

  12. Chant CB, Litchfield R, Griffin S, Thain LM (2007) Humeral head retroversion in competitive baseball players and its relationship to glenohumeral rotation range of motion. J Orthop Sports Phys Ther 37:514–520

    Article  PubMed  Google Scholar 

  13. Cordischi K, Li X, Busconi B (2009) Intermediate outcomes after primary traumatic anterior shoulder dislocation in skeletally immature patients aged 10–13 years. Orthopaedics 32. DOI 10. 3928/01477447–20090728-34

  14. Deitch J, Mehlman CT, Foad SL, Obbehat A, Mallory M (2003) Traumatic anterior dislocation in adolescents. Am J Sports Med 31:758–763

    PubMed  Google Scholar 

  15. Faber KJ, Homa K, Hawkins RJ (1999) Translation of the glenohumeral joint in patients with anterior instability: awake examination versus examination with the patient under anaesthesia. J Shoulder Elbow Surg 8:320–323

    Article  CAS  PubMed  Google Scholar 

  16. Gagey OJ, Gagey N (2001) The hyperabduction test. J Bone Joint Surg 83-B:69–74

    Article  Google Scholar 

  17. Gerber C (1997) Observations in the classification of instability. In: Warner JJP, Iannotti JP, Gerber C (Hrsg) Complex and revision problems in shoulder surgery. Lippincott Raven, Philadelphia, pp 9–18

  18. Good CR, MacGillivray JD (2005) Traumatic shoulder dislocation in the adolescent athlete: advances in surgical treatment. Curr Opin Pediatr 17:25–29

  19. Grumet RC, Bach BR Jr, Provencher MT (2010) Arthroscopic stabilization for first-time versus recurrent dislocation. Arthroscopy 26:239–248

    Article  PubMed  Google Scholar 

  20. Hawkins RJ, Angelo RL (1990) Glenohumeral osteoarthrosis: a late complication of the Putti-Platt repair. J Bone Joint Surg 72-A:1193–1197

    Google Scholar 

  21. Heers G, Müller H, Hedtmann A (2012) Der Einfluss der Hyperlaxität auf die Ergebnisse offener Stabilisierungsoperationen bei posttraumatischen Schulterinstabilitäten. Z Orthop Unfallchir 150:470–476

    CAS  Google Scholar 

  22. Hovelius L (1982) Incidence of shoulder dislocation in Sweden. Clin Orthop 166:127–131

    PubMed  Google Scholar 

  23. Hovelius L, Saebö M (2009) Neer Award 2008: arthropathy after primary anterior shoulder dislocation – 223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg 18:339–347

    Article  PubMed  Google Scholar 

  24. Hovelius L, Sandström B, Saebö M (2006) One hundred eighteen Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: study I – the evolution of dislocation arthropathy. J Shoulder Elbow Surg 15:279–289

    Article  PubMed  Google Scholar 

  25. Hovelius L, Oloffson A, Sandström B, Augustini BG, Krantz L, Fredin H, Tillander B, Skoglund U, Salomonsson B, Novak J, Sennerby U (2008) Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. A prospective twenty-five-year follow-up. J Bone Joint Surg 90-A:945–952

    Article  Google Scholar 

  26. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN (2000) The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg 82-A:35–46

    Google Scholar 

  27. Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I, Sato K (2001) Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging. J Bone Joint Surg 83-A:661–667

    CAS  PubMed  Google Scholar 

  28. Jakobsen BW, Johannsen HV, Suder P, Sojbjerg JO (2007) Primary repair versus conservative treatment of first-time traumatic anterior dislocation of the shoulder: a randomized study with 10-year follow-up. Arthroscopy 23:118–123

    Article  PubMed  Google Scholar 

  29. Kartus C, Kartus J, Matis N, Forstner R, Resch H (2007) Long term independent evaluation after arthroscopic extraarticular Bankart repair with absorbable tacks. A clinical and radiographic study with a seven-to-ten year follow up. J Bone Joint Surg 89-A:1442–1448

    Article  Google Scholar 

  30. Kibler WB, Uhl TL, Maddux JWQ, Brooks PV, Zeller B, McMullen J (2002) Qualitative clinical evaluation of scapular dysfunction: a reliability study. J Shoulder Elbow Surg 11:550–556

    Article  PubMed  Google Scholar 

  31. Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD (2013) Clinical implications of scapular dyskinesis in shoulder injury. Br J Sports Med 47:877–885

    Article  PubMed  Google Scholar 

  32. Kurokawa D, Yamamoto N, Nagamoto H, Omori Y, Tanaka M, Sano H, Itoi E (2013) The prevalence of a large Hill-Sachs lesion that needs to be treated. J Shoulder Elbow Surg 22:1285–1289

  33. Labs K (2003) Schultergelenkinstabilitäten. In: Paul B, Peters M, Ekkernkamp A (Hrsg) Kompendium der medizinischen Begutachtung. Spitta, Balingen, pp 349–363

  34. Leroux T, Wasserstein D, Veillette C, Khosbin A, Henry P, Chahal J, Austin P, Mahomed N, Ogilvie-Harris D (2014) Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada. Am J Sports Med 42:442–450

    Article  PubMed  Google Scholar 

  35. Lewis A, Kitamura T, Bayley JI (2004) Mini symposium: shoulder instability. The classification of shoulder instability: new light through old windows. Curr Orthop 18:97–108

  36. Liavaag S, Stiris MG, Lindland ES, Enger M, Svenningsen S, Brox JL (2009) Do Bankart lesions heal better in shoulders immobilized in external rotation? Acta Orthop 80:579–584

    Article  PubMed Central  PubMed  Google Scholar 

  37. Liavaag S, Brox JL, Pripp AH, Enger M, Soldal LA, Svenningsen S (2011) Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence: a randomized controlled trial. J Bone Joint Surg 93-A:897–904

    Google Scholar 

  38. Ludewig PM, Reynolds JF (1999) The association of scapular kinematics and glenohumeral joint pathologies. J Orthop Sports Phys Ther 39:90–104

    Article  Google Scholar 

  39. Osbahr DC, Cannon DL, Speer KP (2002) Retroversion of the humerus in the throwing shoulder of college baseball pitchers. Am J Sports Med 30:347–353

    PubMed  Google Scholar 

  40. Ovesen J, Nielsen S (1985) Experimental distal subluxation of the glenohumeral joint. Arch Orthop Trauma Surg 104:78–81

    Article  CAS  PubMed  Google Scholar 

  41. Ovesen J, Nielsen S (1986) Anterior and posterior shoulder instability. Acta Orth Scand 57:324–327

    Article  CAS  Google Scholar 

  42. Owens BD, DeBerardino TM, Nelson BJ, Thurman J, Cameron KL, Taylor DC, Uhorchak JM, Arciero RA (2009) Long-term follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocations in young athletes. Am J Sports Med 37:669–673

    Article  PubMed  Google Scholar 

  43. Paterson WH, Throckmorton TW, Koester M, Azar FM, Kuhn JE (2010) Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. J Bone Joint Surg 92-A:2924–2933

    Google Scholar 

  44. Pollock RG, Wang VM, Bucchieri SJ, Cohen NP, Huang CY, Pawluk RJ, Flatow EL, Bigliani LU, Mow VC (2000) Effects of repetitive subfailure strains on the mechanical behavior of the inferior glenohumeral ligament. J Shoulder Elbow Surg 9:427–435

    Article  CAS  PubMed  Google Scholar 

  45. Pouliart N, Gagey O (2005a) Significance of the latissimus dorsi for shoulder instability. I. Variations in its anatomy around the humerus and scapula. Clin Anat 18:493–499

    Article  CAS  Google Scholar 

  46. Pouliart N, Gagey O (2005b) Significance of the latissimus dorsi for shoulder instability. II. Its influence on dislocation behaviour in a sequential cutting protocol of the glenohumeral capsule. Clin Anat 18:500–509

    Article  CAS  Google Scholar 

  47. Privitera DM, Bisson LJ, Marzo LM (2012) Minimum 10-year follow-up of arthroscopic intraarticular Bankart repair using bioabsorbable tacks. Am J Sports Med 40:100–107

    Article  PubMed  Google Scholar 

  48. Provencher MT, Mologne TS, Hongo M, Zhao K, Tasto JP, An KN (2007) Arthroscopic versus open rotator interval closure: biomechanical evaluation of stability and motion. Arthroscopy 23:583–592

    Article  PubMed  Google Scholar 

  49. Reagan KM, Meister K, Horodyski MB, Werner DW, Carruthers C, Wilk K (2002) Humeral retroversion and its relationship to glenohumeral rotation in the shoulder of college baseball players. Am J Sports Med 30:354–360

    CAS  PubMed  Google Scholar 

  50. Robinson CM, Seah M, Akhtar MA (2011) The epidemiology, risk of recurrence, and functional outcome after an acute posterior dislocation of the shoulder. J Bone Joint Surg 93-A:1605–1613

    Google Scholar 

  51. Shafer BL, Mihata T, McGarry MH, Tibone JE, Lee TY (2008) Effect of capsular plication and rotator interval closure in simulated multidirectional shoulder instability. J Bone Joint Surg 90-A:136–144

    Article  Google Scholar 

  52. Speer KP, Deng X, Borrero S, Torzilli PA, Altchek DA, Warren RF (1994) Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg 76-A:1819–1826

    Google Scholar 

  53. Struyf F, Cagnie B, Cools A, Baertl I, Brempt JV, Struyf P, Meeus M (2014) Scapulothoracic muscle activity and recruitment timing in patients with shoulder impingement symptoms and glenohumeral instability. J Electromyogr Kinesiol 24:227–284. DOI 10.1016/j.jelekin.2013.12.002

  54. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiy A (2003) Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg 85-A:878–884

    PubMed  Google Scholar 

  55. Thomas SC, Matsen FA 3rd (1989) An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior instability. J Bone Joint Surg 71-A:506–513

    Google Scholar 

  56. Turkel SJ, Panio MW, Marshall JL, Girgis FG (1981) Stabilising mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg 63-A:1208–1217

    Google Scholar 

  57. Vavken P, Sadoghi P, Quidde J, Lucas R, Delaney R, Mueller AM, Rosso C, Valdebarrano V (2014) Immobilization in internal or external rotation does not change recurrence rates after traumatic shoulder dislocation. J Shoulder Elbow Surg 23:13–19

    Article  PubMed  Google Scholar 

  58. Visser CP, Coene LN, Brand R, Tavy DL (1999) The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg 81-B:679–685

    Article  Google Scholar 

  59. Walia P, Aminaci A, Jones MH, Fening SD (2013) Theoretical model of the effect of combined glenohumeral bone defects on anterior shoulder instability: a finite element approach. J Orthop Res 31:601–607

    Article  PubMed  Google Scholar 

  60. Wang VM, Sugalski MT, Levine WN, Pawluk RJ, Mow VC, Bigliani LU (2005) Comparison of glenohumeral mechanics following a capsular shift and anterior tightening. J Bone Joint Surg 87-A:1312–1322

    Article  Google Scholar 

  61. Wasserstein D, Dwyer T, Veillette C, Ghandi R, Chahal J, Mahomed N, Ogilvie-Harris D (2013) Predictors of dislocation and revision after shoulder stabilization in Ontario, Canada, from 2003 to 2008. Am J Sports Med 41:2034–2040

    Article  PubMed  Google Scholar 

  62. Werner A, Lichtenberg S, Nikolic A, Habermeyer P (2003) Intraartikuläre Pathologie bei atraumatischer Schulterluxation. Unfallchirurg 106:110–113

    Article  CAS  PubMed  Google Scholar 

  63. Wheeler JH, Ryan JB, Arciero RA, Molinari RN (1989) Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes. Arthroscopy 5:213–217

    Article  CAS  PubMed  Google Scholar 

  64. Whelan DB, Litchfield R, Wambolt E, Dainty KN (2014) External rotation immobilization for primary shoulder dislocation: a randomized controlled trial. Clin Orthop Relat Res. doi:10.1007/s11999-013-3432-6

  65. Yamamoto N, Itoi E, Abe H, Minagawa H, Seki M, Shimada Y, Okada K (2007) Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elbow Surg 16:649–656

    Article  PubMed  Google Scholar 

  66. Yamamoto N, Itoi E, Abe H, Kikuchi K, Seki N, Minagawa H, Tuoheti Y (2009) Effect of an anterior glenoid defect on anterior shoulder stability: a cadaver study. Am J Sports Med 37:949–957

    Article  PubMed  Google Scholar 

  67. Yamamoto N, Muraki T, Sperling JW, Steinmann SP, Cofield RH, Itoi E, An KN (2010) Stabilizing mechanism in bone grafting of a large glenoid defect. J Bone Joint Surg 92-A:2059–2066

    Article  Google Scholar 

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Einhaltung ethischer Richtlinien

Interessenkonflikt. A. Hedtmann und J. Kircher geben an, dass kein Interessenkonflikt besteht.

Der Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Abteilung Orthopädie II, Schulter- und Ellenbogenchirurgie, Klinik Fleetinsel Hamburg, Admiralitätstr. 3–4, 20489, Hamburg, Deutschland

    A. Hedtmann MD, PhD & J. Kircher

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Hedtmann, A., Kircher, J. Instabilität des Glenohumeralgelenks. Obere Extremität 9, 68–77 (2014). https://doi.org/10.1007/s11678-014-0260-6

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