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Differenzialtherapie massiver Rotatorenmanschettenläsionen

How to treat massive rotator cuff tears

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Zusammenfassung

Die erfolgreiche Therapie massiver Rotatorenmanschettenrupturen stellt hohe Anforderungen an den Schulterchirurgen, da das Behandlungskonzept an viele individuelle Patientenparameter adaptiert werden muss.

Zunächst sollte entschieden werden, ob die Qualität der Muskel-/Sehneneinheit geeignet ist, eine direkte Naht durchzuführen. Falls die Degeneration zu weit fortgeschritten ist und zu viel Spannung bei der Reposition ausgeübt werden muss, kann man es evtl. bei einem partiellen Verschluss belassen, die Bicepssehne zur Defektdeckung verwenden oder einen lokalen Muskeltransfer mit z. B. dem M. subscapularis oder M.  infraspinatus durchführen.

Bei einem nicht mehr zu verschließenden Defekt und fehlenden Arthrosezeichen hat man die Wahl zwischen einer Tuberkuloplastik/subakromialen Dekompression bei älteren Patienten mit geringem funktionellem Anspruch oder einem Muskel-/Sehnentransfer bei Patienten <60 Jahre mit höheren funktionellen Ansprüchen. Bei posterosuperioren Defekten kann man einen M.-deltoideus-Lappen als Puffer unter dem Akromion durchführen oder als aktiven Muskelsehnentransfer einen M.-latissimus-dorsi-Transfer. Bei anterosuperioren Defekten empfiehlt sich der M.-pectoralis-Transfer. Bei einer Dezentrierung des Humeruskopfes, Arthrosezeichen und fortgeschrittenem Alter (>70 Jahre) kann die Implantation einer inversen Prothese erwogen werden.

Abstract

The treatment of massive rotator cuff tears must be adapted to the patient’s individual needs and preoperative parameters to achieve the best outcome. First, the shoulder surgeon has to determine whether a direct transosseous repair is possible. If there is not enough remaining tissue, the tissue is atrophic, and the tendon stump can be reduced only with great tension, one can use a margin convergence technique for partial closure, perform a biceps tendoplasty, or perform local tendon transfers with the subscapularis or infraspinatus muscle.

If the defect cannot be sufficiently closed, elderly patients with low demands can be treated with tubercleplasty/subacromial decompression, whereas patients younger than 60 years with higher demands should receive muscle and tendon transfers. A balanced posterosuperior defect can be reconstructed by a deltoid muscle transfer, in contrast to an unbalanced one, which is best treated with an active transfer of the latissimus dorsi muscle and tendon. Anterosuperior defects can be addressed by a pectoralis muscle transfer. If the humeral head is superiorly migrated, if signs of osteoarthritis are present, and if the patient is older than 70 years, a reverse prosthesis can be implanted as a salvage procedure.

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Abbreviations

AHA:

akromiohumerale Abstand

BS:

Bicepssehne

ISP:

M. infraspinatus

SSP:

M. supraspinatus

SSC:

M. subscapularis

RM:

Rotatorenmanschette

SAD:

subakromiale Dekompression

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  1. Sektion Schulter und Ellenbogenchirurgie, Orthopädische Universitätsklinik Heidelberg, Schlierbacher Landstr. 200a, 69118, Heidelberg, Deutschland

    P. Kasten & M. Loew

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  1. P. Kasten
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  2. M. Loew
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Correspondence to P. Kasten.

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Kasten, P., Loew, M. Differenzialtherapie massiver Rotatorenmanschettenläsionen. Orthopäde 36, 855–861 (2007). https://doi.org/10.1007/s00132-007-1137-9

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