Therapie von Degenerationen und Verletzungen der Rotatorenmanschette

Zusammenfassung

Die Prävalenz von Rotatorenmanschettenläsionen steigt im Alter auf bis zu 19–32 % für Komplettrupturen und auf bis zu 13–32 % für Partialrupturen. Hinsichtlich der Therapieentscheidung ist eine Zuordnung der Partialrupturen – artikulärseitig, bursaseitig oder intratendinös – anzustreben. Komplettrupturen sind möglichst hinsichtlich der Größe, der Retraktion, des anterodorsalen Rupturausmaßes, einer Verfettung, der Atrophie als auch einer interstitiellen Fibrose präoperativ zuzuordnen. Diese Parameter gelten als wichtige prognostische Faktoren hinsichtlich einer operativen Rekonstruierbarkeit und deren Erfolgsaussicht. Symptomatische bzw. progrediente Partialrupturen sowie Komplettrupturen bedürfen in aller Regel einer operativen Rekonstruktion. Klinische Studien zeigen keinen wissenschaftlichen Konsens in Bezug auf Vorteile im Outcome nach arthroskopischer oder Mini-open-Technik. Beide Versorgungsstrategien sollten den Kriterien von Gerber zur Rekonstruktion einer Rotatorenmanschettenruptur standhalten: hohe Primärstabilität, Reduktion von Mikrobewegungen, minimale Gewebetraumatisierung sowie Aufrechterhaltung der Rekonstruktionsstabilität bis zur fibroblastischen Einheilung. In Revisionssituationen bzw. bei schlechter Sehnenqualität zeigen erste wissenschaftliche Daten einen positiven Effekt verschiedener additiver biologischer Augmentationsverfahren. Bei der Anwendung am Menschen besteht mangels High-Level-Studien jedoch noch eine wenig gesicherte Evidenz.

Abstract

The prevalence of rotator cuff lesions is age-dependent and up to 19–32 % for full-thickness ruptures and 13–32 % for partial-thickness lesions respectively. The therapy of partial-thickness ruptures should be considered in accordance with the articular, bursal or intratendinous location of the lesion. The therapy of full-thickness ruptures should be applied in accordance with topography and area of defect, retraction, atrophy and fatty infiltration. These parameters are considered to be important prognostic factors for the intraoperative repairability and the success of the surgery. Symptomatic or chronically progredient partial-thickness lesions as well as full-thickness lesions should generally be treated by means of surgical reconstruction. No current scientific consensus exists regarding improved clinical outcome data after the surgical approach in mini-open or arthroscopic technique. Both procedures should meet the requirements of the Gerber criteria for rotator cuff reconstruction: high primary stability, reduction of micro-movements, minimized approach associated morbidity and persisting stability to enable the fibroblastic tendon-to-bone healing. Current studies revealed a potential improvement of the tendon-to-bone healing by the application of several biologic augmentations. At the moment, these additive procedures can be applied in revision situations and for complex rotator cuff lesions with low tendon quality. No high-level in-vivo investigations concerning the human shoulder exist in the current literature that show evidence-based improvements by the additively applied biologic augmentations for rotator cuff repair.

Key words

Schulterverletzung - Rotatorenmanschettenläsion - Komplettruptur der Rotatorenmanschette - Partialruptur der Rotatorenmanschette - Rekonstruktion der Rotatorenmanschette

Key words

shoulder trauma - rotator cuff lesion - full-thickness rupture of the rotator cuff - partial-thickness rupture of the rotator cuff - rotator cuff repair

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