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Latissimus-dorsi-Transfer bei nichtrekonstruierbarem Rotatorenmanschettendefekt

Indikation, Operationstechnik und Technikmodifikationen

Latissimus dorsi transfer for the treatment of irreparable rotator tears

Indication, surgical technique, and modifications

  • Operative Techniken
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Zusammenfassung

Operationsziel

Verbesserung der glenohumeralen Zentrierung und der Außenrotationskraft durch den Transfer des M. latissimus dorsi auf das Tuberculum majus bzw. den proximalen lateralen Humerus.

Indikationen

Nichtrekonstruierbare posterosuperiore Rotatorenmanschettenruptur.

Kontraindikationen

Fortgeschrittene Defektarthropathie, Subskapularisläsion, Deltoideusdefekt, Axillarisparese.

Operationstechnik

Diagnostische Arthroskopie in Seitenlage. Anschlingen der langen Bizepssehne und Tenotomie supraglenoidal. Dorsaler Zugang. Präparation und Mobilisation eines gestielten Latissimus-dorsi-Lappens. Zweiter Zugang ventral mit Deltasplit. Debridement der Sehnenstümpfe der Rotatorenmanschette. Einbringen von Schraubfadenankern in das Tuberculum majus. Durchzug des Muskellappens von inferior des posterioren M. deltoideus nach intraartikulär. Refixation auf dem Tuberculum majus (ggf. Vernähen mit residualem Rotatorenmanschettengewebe).

Weiterbehandlung

Ruhigstellung in einem Thoraxabduktionsgips für 6 Wochen. Passive Beübung der Schulter aus dem Gips heraus (IRO/ARO 0°-0°-frei und ABD/ADD frei-45°-0°). Aktive assistive Übungen ab der 4. Woche postoperativ. Zunehmend Freigabe der passiven Beweglichkeit ab der 7. Woche. Freie aktive Beweglichkeit ab der 10. Woche postoperativ.

Ergebnisse

Es wurden 17 Patienten nach einem durchschnittlichen Nachuntersuchungszeitraum von 57,6 (SD 27,5) Monaten untersucht. Das Durchschnittsalter betrug zum Operationszeitpunkt 55,6 (SD 7,7) Jahre. Es wurde im Durchschnitt ein Constant-Score von 64,4 (SD 17,4) Punkten erzielt. Die aktive Außenrotation in 0°-Abduktion betrug im Mittel 16° (SD 17). Die 4 Patienten (23%) mit sonographisch nachgewiesener Reruptur zeigten deutlich schlechtere klinische Ergebnisse.

Abstract

Objective

Improvement of glenohumeral dynamic centering and active external rotation by a transfer of the latissimus dorsi tendon to the greater tuberosity or the lateral proximal humerus.

Indications

Irreparable posterosuperior rotator cuff tears.

Contraindications

Cuff tear arthropathy, subscapularis tendon tear, deltoid insufficiency, palsy of the axillary nerve.

Surgical technique

Diagnostic arthroscopy in lateral decubitus position. Placement of suture through the biceps tendon and supragleonidal tenotomy. Posterior approach. Preparation and mobilization of a pedicled latissimus dorsi flap. Second anterior incision with delta split. Debridement of the torn rotator cuff. Insertion of suture anchors in the greater tuberosity. Passing of the muscle flap inferior to the posterior deltoid and fixation with suture anchors to the greater tuberosity (where applicable suturing with remaining rotator cuff tissue).

Postoperative management

Immobilization in a thorax abduction cast for 6 weeks. Passive exercises out of the cast (IR/ER 0-0-free and ABD/ADD free-45-0°). Active assistive exercises from week 4 postoperatively. Stepwise increase of passive range of motion from week 7. Unlimited active range of motion from week 10.

Results

After an average follow-up of 57.6 (SD 27.5) months 17 patients were examined clinically. The average age at time of surgery was 55.6 (SD 7.7) years. At follow-up the patients showed an average Constant score of 64.4 points (SD 17.4). The active external rotation in 0° abduction was 16° (SD 17). The 4 patients (23%) with a sonographically-detected retear of the latissimus flap presented worse clinical results.

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Authors and Affiliations

  1. Orthopädische Chirurgie, Schulthess Klinik, Lengghalde 2, 8008, Zürich, Schweiz

    S. Buchmann

  2. Abteilung und Poliklinik für Sportorthopädie, Technische Universität München, München, Deutschland

    S. Buchmann, J.E. Plath & A.B. Imhoff

Authors
  1. S. Buchmann
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  2. J.E. Plath
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  3. A.B. Imhoff
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Correspondence to S. Buchmann.

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Buchmann, S., Plath, J. & Imhoff, A. Latissimus-dorsi-Transfer bei nichtrekonstruierbarem Rotatorenmanschettendefekt. Oper Orthop Traumatol 24, 502–512 (2012). https://doi.org/10.1007/s00064-012-0162-y

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