Unter der Leitung von GOTS -Vizepräsident – Österreich Dr. Klaus Dann und Hausherr Dr. Christof Murr fand vom 13. – 16.04. die 4. Fortbildungsveranstaltung der GOTS Österreich im Hotel Albona Nova in Zürs am Arlberg statt.
Auch dieses Jahr war der Seminarraum mit ca. 90 Teilnehmern aus der Schweiz, Deutschland, USA und Österreich bis auf den letzten Platz ausgebucht. Ursprüngliche Überlegungen das Meeting zu vergrößern haben wir nicht nur aus Kostengründen, sondern auch um den familiären offenen Charakter der Veranstaltung zu erhalten, wieder verworfen.
Thema der Fortbildung war: Acromioclavicular – und Patellofemoralgelenk – akute und chronische Problem.
Die akuten Verletzungen und chronischen Probleme dieser beiden Gelenke werden noch immer sehr unterschiedlich bewertet und vielfältig behandelt.
Zwei “Stiefkinder der Orthopädie und Traumatologie” mußten in sehr komprimierter Form in zwei Tagen abgehandelt werden und zusätzlich sollte ein allgemeingültiger Konsens erarbeitet werden.
Ehrengast der Veranstaltung war Herr Prof. Dr. Dieter Kohn , Orthopädische Universitätsklinik Homburg / Saar. Auch unser Präsident der Gesellschaft Herr P.D. Dr. Martin Engelhardt, Orthopädische Universitätsklinik Frankfurt, scheute trotz tiefwinterlicher Verhältnisse nicht den langen Anfahrtsweg und konnte dank Bahn am Freitag abend zu uns stoßen. Dr. Tom Minas , Knorpelspezialist aus Boston wurde ebenso über den großen Teich geflogen und erstmals mit der österreichischen Bergwelt konfrontiert..
Am Freitag stand dann das AC-Gelenk auf dem Programm:
H. Traxler vom 1. Anatomischen Institut Wien brachte uns in seinem ausführlichen Referat , die Besonderheiten des AC-Gelenkes und der umgebenden Strukturen näher.
Er wies besonders auf die durchschnittliche kleine Gelenksfläche von 0,8 1,0 cm2 und den oftmals vor allem in höherem Alter nur noch rudimentären Diskus und des großen Kapselraumes des Gelenkes hin. Weiters wurde für alle von uns erstmals die Bedeutung des Ligamentum Coracoacromiale mit seinen Ruffini-, Pacini- und Golgikörpern – ähnlichen Rezeptoren herausgestrichen, die in Zusammenhang mit der Rotatorenmanschette eine wichtige Funktion ausüben. Die Kardanwirkung der Clavicula als Rotationsachse wurde ebenso dargestellt.
G. Schippinger, Graz stellte in seinem Referat die Klassifikation nach Rockwood und Tossy für jedermann klar dar und wies auch auf die Gefahr einer Fehlinterpretation der Rockwood IV Verletzung mit konsekutiver dorsaler Fehlstellung hin. Daher sein Tip immer eine Aufnahe in zweiter Ebene speziell bei nicht eindeutigen Zerreißungen durchführen.
J. Hofmann, Wien präsentierte sehr ausführlich die Untersuchungen des AC-Gelenkes und legte wert auf den Horizontal- Adduktiosntest, Cross-Body Action, forcierte Adduktion am hängenden Arm und bei Bedarf auch auf Infiltrationstest. Die Differentiladiagnosen wurden ebenso sehr ausführlich herausgestrichen.
Als nächster hat dann F. Kainberger, Wien , über die Bildgebung des AC-Gelenkes gesprochen. Interessant dazu scheint die Ausführung, dass in britischen Guidelines aus Strahlenschutzgründen zur Primärdiagnostik kein Röntgen mehr angegeben wird, hingegen in den österreichischen sehr wohl das Röntgen als bildgebendes Diagnostikum der ersten Wahl empfohlen wird. Die Bedeutung der Belastungsaufnahmen wird in jüngster Literatur wegen zu geringer Behandlungskonsequenz angezweifelt. Ebenso ist die korrekte Einneigung der Röhre von großer Bedeutung. Mittels MRT Können hohe Auflösungen erzielt werden, dies erfordert jedoch schnelle Sequenzen. Diese Geräte stehen derzeit aus Kosten und Platzgründen noch nicht überall zur Verfügung. Seitens der Sonographie steht uns ein kostengünstiges, wenn auch nur in erfahrener Hand aussagekräftiges Medium zur Hand.
Auf die atraumatische Osteolyse bei Kraftsportlern im Bereich des AC-Gelenkes wurde dann ebenso eingegangen.
K. Golser, Innsbruck ,sprach dann über die Indikationen zur konservativen und operativen Versorgung der AC-Gelensksprengung. Sein Statement ” wir indizieren und operieren” sollte jedem Operateur bewußt sein. Je nach Graduierung der Läsion erfolgen dann auch die Rechtfertigung für die Operation.
Rockwood , Tossy I, II sind heute unumstritten bei der Akutverletzung eine Domäne der konservativen Therapie. Es kann jedoch auch sekundär eine Typ I oder II Läsion innerhalb relativ kurzer Zeit zur Arthrose und Schmerzen führen sodass wir sekundär zur Operation gezwungen werden. Die ist in aller Regel eine isolierte laterale Clavicularesektion ohne Bandoperation.
Rockwood Typ III Zerreissungen werden nach wie vor kontrovers diskutiert. Tatsache ist in einer großen Zahl von Publikationen sind die funktionellen Ergebnisse besser als die primär operativ versorgten. Wir müssen uns auch im klaren sein, dass wir, falls es zur Operation z.B. Zuggurtung kommt , aus einer III-er Läsion durch Abpräparieren der Muskelansätze eine V-er machen müssen um die Implantate einzubringen.
Die Indikationsstellung für Typ III – Läsionen bei Überkopfsportler oder Überkopfarbeitern muß nach exakter Aufklärung individuell gestellt werden. Rockwood Typ IV-Verletzungen bedürfen immer einer operativen Versorgung und werden zuoft als Typ II Läsionen verkannt. Daher immer eine axiale Aufnahme anfertigen.
Typ V- Läsionen bedürfen ebenso immer einer operativen Versorgung da neben allen Bändern auch die Muskelansätze des Deltoideus und Trapezius abgerissen und daher zu rekonstruieren sind.Typ VI-Läsionen wurden bisher von keinem der Kursteilnehmer gesehen und dürften demzufolge auch entsprechend selten sein. Die Operative Versorgung steht auf Grund der Verhakung unter den Processus coracoideus klar fest.
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