Diagnostik und Therapie der vorderen Erstluxation der Schulter

Zusammenfassung

Eine detaillierte Anamneseerhebung und seitenvergleichende klinische Untersuchung beider Schultergelenke sind die entscheidenden klinischen Kriterien zur Differenzierung zwischen einer traumatischen und atraumatischen Schulterluxation. Das Therapiespektrum nach Erstluxation der Schulter reicht von der rein funktionellen Therapie über die Ruhigstellung im Gilchrist-Verband bis zu arthroskopischen oder offenen Stabilisierungsoperationen. Junge Patienten (< 30 Jahre) nach einer traumatischen Erstluxation durch adäquates Trauma, mit unidirektionaler Instabilität, dem Nachweis einer Hill-Sachs-Läsion und sportlicher Aktivität sollten bei Therapiewunsch bereits nach der Erstluxation einer operativen Stabilisierung zugeführt werden. Das Operationsprinzip besteht in einer Refixation des abgerissenen Labrum glenoidale und des anterioren Anteils des inferioren glenohumeralen Bandes am vorderen Glenoidrand. Die Entwicklung arthroskopischer Operationsverfahren ist inzwischen soweit fortgeschritten, dass die Rekonstruktion des traumatisch abgelösten Kapsel-Labrum-Komplexes am Glenoidrand mit verschiedenen Nahttechniken realisierbar ist. Bei Abrissfrakturen des Glenoids (knöcherne Bankart-Läsion) besteht, bedingt durch den Verlust der Gelenkfläche, eine hohe Gefahr der Reluxation. Eine offene Refixation des Bankart-Fragments mittels Schraubenosteosynthese ist die Therapie der Wahl.

Abstract

A detailed history of the patient and a physical examination of both shoulder joints are imperative to differentiate between traumatic and atraumatic shoulder dislocations. Therapeutic options to stabilize the shoulder range from functional therapy and immobilization to arthroscopic or open surgery. Young patients (< 30 years) with a traumatic first-time anterior shoulder dislocation, unidirectional instability, a Hill-Sachs-lesion, and sports activity should be treated surgically. The surgical principle consists of a refixation of the torn labrum and the anterior band of the inferior glenohumeral ligament to the anterior glenoid rim. Repair of the capsule-labrum-complex is feasible with various arthroscopic fixation techniques. A bony Bankart-lesion leads to a high reluxation rate and should be treated with an open screw osteosynthesis.

Literatur

• 1 Arciero R A, Wheeler J H, Ryan J B, McBride J T. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations.  Am J Sports Med. 1994;  22 589-594
• 2 Arciero R A, Pierre St P. Acute shoulder dislocation. Indications and techniques for operative management.  Clin Sports Med. 1995;  14 937-953
• 3 Arciero R A, Taylor D C. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study.  J Bone Joint Surg [Am]. 1998;  80 299-300
• 4 Baker C L. Intraarticular pathology in acute, first-time anterior shoulder dislocation: an arthroscopic study.  Arthroscopy. 1994;  10 478-479
• 5 Baker Jr C L. Arthroscopic evaluation of acute initial shoulder dislocations.  Instr Course Lect. 1996;  45 83-89
• 6 Bigliani L U, Newton P M, Steinmann S P, Connor P M, McLlveen S J. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder.  Am J Sports Med. 1998;  26 41-45
• 7 Burkhead Jr W Z, Rockwood Jr C A. Treatment of instability of the shoulder with an exercise program.  J Bone Joint Surg [Am]. 1992;  74 890-896
• 8 Calandra J J, Baker C L, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations.  Arthroscopy. 1989;  5 254-257
• 9 Fabbriciani C, Milano G, Demontis A, Fadda S, Ziranu F, Mulas P D. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study.  Arthroscopy. 2004;  20 456-462
• 10 Fery A, Sommelet J. Erect dislocation of the shoulder (luxatio erecta humeri). General review apropos of 10 cases.  Int Orthop. 1987;  11 95-103
• 11 Gerber C, Nyffeler R W. Classification of glenohumeral joint instability.  Clin Orthop. 2002;  400 65-76
• 12 Habermeyer P, Jung D, Ebert T. Treatment strategy in first traumatic anterior dislocation of the shoulder. Plea for a multi-stage concept of preventive initial management.  Unfallchirurg. 1998;  101 328-341 327-(Discussion)
• 13 Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study.  J Shoulder Elbow Surg. 1999;  8 66-74
• 14 Handoll H H, Almaiyah M A, Rangan A. Surgical versus non-surgical treatment for acute anterior shoulder dislocation.  Cochrane Database Syst Rev. 2004;  1 CD004325
• 15 Hawkins R J, Bell R H, Hawkins R H, Koppert G J. Anterior dislocation of the shoulder in the older patient.  Clin Orthop. 1986;  206 192-195
• 16 Hoelen M A, Burgers A M, Rozing P M. Prognosis of primary anterior shoulder dislocation in young adults.  Arch Orthop Trauma Surg. 1990;  110 51-54
• 17 Hovelius L. Shoulder dislocation in Swedish ice hockey players.  Am J Sports Med. 1978;  6 373-377
• 18 Hovelius L. Incidence of shoulder dislocation in Sweden.  Clin Orthop. 1982;  166 127-131
• 19 Hovelius L, Lind B, Thorling J. Primary dislocation of the shoulder. Factors affecting the two-year prognosis.  Clin Orthop. 1983;  176 181-185
• 20 Hovelius L, Eriksson K, Fredin H. et al . Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment.  J Bone Joint Surg [Am]. 1983;  65 343-349
• 21 Hovelius L, Augustini B G, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study.  J Bone Joint Surg [Am]. 1996;  78 1677-1684
• 22 Imhoff A B, Roscher E, Konig U. Arthroscopic shoulder stabilization. Differentiated treatment strategy with Suretac, Fastak, Holmium: YAG-laser and electrosurgery.  Orthopäde. 1998;  27 518-531
• 23 Itoi E, Tabata S. Rotator cuff tears in anterior dislocation of the shoulder.  Int Orthop. 1992;  16 240-244
• 24 Itoi E, Hatakeyama Y, Urayama M, Pradhan R L, Kido T, Sato K. Position of immobilization after dislocation of the shoulder. A cadaveric study.  J Bone Joint Surg [Am]. 1999;  81 385-390
• 25 Itoi E, Lee S B, Berglund L J, Berge L L, An K N. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study.  J Bone Joint Surg [Am]. 2000;  82 35-46
• 26 Itoi E, Hatakeyama Y, Kido T. et al . A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study.  J Shoulder Elbow Surg. 2003;  12 413-415
• 27 Kim S H, Ha K I, Cho Y B, Ryu B D, Oh I. Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up.  J Bone Joint Surg [Am]. 2003;  85 1511-1518
• 28 Kirkley A, Griffin S, Richards C, Miniaci A, Mohtadi N. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder.  Arthroscopy. 1999;  15 507-514
• 29 Kirkley A, Werstine R, Ratjek A, Griffin S. Prospective randomized clinical trial comparing effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long term evaluation.  Arthroscopy. 2005;  21 55-63
• 30 Mazzocca A D, Brown F M, Carreira D S, Hayden J, Romeo A A. Arthroscopic anterior shoulder stabilization of collision and contact athletes.  Am J Sports Med. 2005;  33 52-60
• 31 Matsen F A. Practical Evaluation and Management of the Shoulder. Philadelphia; W. B. Saunders Company 1994
• 32 McLaughlin H L, MacLellan D I. Recurrent anterior dislocation of the shoulder. II. A comparative study.  J Trauma. 1967;  7 191-201
• 33 Neer C S. Shoulder Reconstruction. Philadelphia; Saunders 1990
• 34 Neer 2nd C S. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: a preliminary report, 1980.  J Bone Joint Surg [Am]. 2001;  83 1586
• 35 Norlin R. Intraarticular pathology in acute, first-time anterior shoulder dislocation: an arthroscopic study.  Arthroscopy. 1993;  9 546-549
• 36 Resch H, Wykypiel H F, Maurer H, Wambacher M. The antero-inferior (transmuscular) approach for arthroscopic repair of the Bankart lesion: an anatomic and clinical study.  Arthroscopy. 1996;  12 309-319 320-322 (Discussion)
• 37 Rockwood C A. The Shoulder. 3rd ed. Philadelphia; Saunders 2004
• 38 Ryf C, Matter P. The initial traumatic shoulder dislocation. Prospective study.  Z Unfallchir Versicherungsmed. 1993;  Suppl 1 204-212
• 39 Schneeberger A G, Hersche O, Gerber C. The unstable shoulder. Classification and therapy.  Unfallchirurg. 1998;  101 226-231
• 40 Simonet W T, Cofield R H. Prognosis in anterior shoulder dislocation.  Am J Sports Med. 1984;  12 19-24
• 41 Singer G C, Kirkland P M, Emery R J. Coracoid transposition for recurrent anterior instability of the shoulder. A 20-year follow-up study.  J Bone Joint Surg [Br]. 1995;  77 73-76
• 42 Taylor D C, Arciero R A. Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations.  Am J Sports Med. 1997;  25 306-311
• 43 Vermeiren J, Handelberg F, Casteleyn P P, Opdecam P. The rate of recurrence of traumatic anterior dislocation of the shoulder. A study of 154 cases and a review of the literature.  Int Orthop. 1993;  17 337-341
• 44 Walch G, Boileau P, Martin B, Dejour H. Unreduced posterior luxations and fractures-luxations of the shoulder. Apropos of 30 cases.  Rev Chir Orthop Reparatrice Appar Mot. 1990;  76 546-558
• 45 Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S. Arthroscopic stabilization for recurrent anterior shoulder dislocation: results of 59 cases.  Arthroscopy. 1995;  11 173-179
• 46 Warner J JP, Iannotti J P, Gerber C, Filer W R. Complex and Revision Problems in Shoulder Surgery. Philadelphia; Lippincott-Raven 1997
• 47 Weber B G, Simpson L A, Hardegger F. Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion.  J Bone Joint Surg [Am]. 1984;  66 1443-1450
• 48 Wheeler J H, Ryan J B, Arciero R A, Molinari R N. Arthroscopic versus nonoperative treatment of acute shoulder dislocations in young athletes.  Arthroscopy. 1989;  5 213-217
• 49 Wintzell G, Haglund-Akerlind Y, Tengvar M, Johansson L, Eriksson E. MRI examination of the glenohumeral joint after traumatic primary anterior dislocation. A descriptive evaluation of the acute lesion and at 6-month follow-up.  Knee Surg Sports Traumatol Arthrosc. 1996;  4 232-236