Zusammenfassung
Die rekonstruktive Handchirurgie kann Patienten mit Lähmungen der oberen Extremität infolge einer Verletzung des Halsrückenmarks entscheidend helfen, weniger von fremder Hilfe abhängig zu sein und ihr Leben wieder selbst zu gestalten. Durch Verlagerungen von Muskel-Sehnen-Einheiten können Schlüsselfunktionen wie die Ellenbogen- und Handgelenkstreckung und ein kontrolliertes Greifen wiederhergestellt, Gelenke bei Spastizität stabilisiert, Schmerzen gemindert und Kontrakturen vorgebeugt werden. Die Wahl des am besten geeigneten Spendermuskels stützt sich auf ein genaues Verständnis der biomechanischen Grundlagen der Muskel-Sehnen-Einheit. Durch die intraoperative Messung der Sarkomerlänge kann das Verhältnis zwischen Muskellänge und Muskelkraft optimal eingestellt werden und so vor allem eine Überdehnung des Muskels mit erheblich verminderter Kraftentwicklung verhindert werden. Die passive Spannung des Muskels wird durch Stützproteine innerhalb des Sarkomers und durch die extramuskuläre Matrix verliehen. Die Erkenntnis, dass spastische Muskeln steifere und kürzere Sarkomere und eine extrazelluläre Matrix mit ungünstigeren mechanischen Eigenschaften aufweisen als normale Muskelfasern, beeinflusst das chirurgische Vorgehen. Neben der Grundlagenforschung sind vor allem klinische Studien in Zusammenarbeit mit internationalen Zentren wichtig, um die Entwicklung verfeinerter Techniken zur chirurgischen Rekonstruktion und Rehabilitation der Arm- und Handfunktion von tetraplegischen Patienten voranzubringen.
Abstract
Reconstructive hand surgery improves the ability to meet the needs of daily life and the independence of patients who have lost their upper extremity function due to cervical spinal cord injury. Tendon transfer procedures provide the potential to restore key functions, such as elbow and wrist extension or hand grip control, ameliorate joint balance, reduce pain in spasticity and prevent joint contractures. The choice of the optimal donor muscle should be based on a thorough understanding of the biomechanical principles of the muscle-tendon unit. Intraoperative sarcomere length measurements allow to predict and set the optimal muscle-tendon unit length during reconstructive upper extremity surgery in order to prevent overstretch which may lead to insufficient active force generation. Macro-proteins and the extracellular matrix are in charge of the muscle ultrastructure, elasticity and thus passive muscle tension. Spastic muscles are characterized by greater stiffness, a shorter sarcomere length and an extracellular matrix with inferior mechanical properties. Basic science research and clinical studies in cooperation with international centers are of great importance to promote the development of refined techniques of surgical reconstruction and postoperative rehabilitation of upper extremity function in tetraplegic patients.
Schlüsselwörter
Tetraplegie - Muskeltransposition - Muskelarchitektur - Sarkomerlänge - Muskelspannung
Key words
Tetraplegia - tendon transfer - muscle mechanics - muscle architecture - sarcomere length - muscle tension
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Prof. M. D., Ph. D. Jan Fridén
Handkirurgiska Kliniken
Sahlgrenska Universitetshuset
413 45 Göteborg
Schweden
eMail: jan.friden@orthop.gu.se
