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Knöcherne Glenoidrekonstruktion in der Revisionsendoprothetik

Bony glenoid reconstruction in revision arthroplasty

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Zusammenfassung

Glenoidpathologien sind eine der Hauptindikationen für Revisionen von Schulterendoprothesen. In den meisten Fällen ist der glenoidale Knochendefekt mit Defekten oder Insuffizienzen der Rotatorenmanschette verbunden, sodass als Revisionsimplantat nur die inverse Schultertotalendoprothese infrage kommt. Zur dauerhaft stabilen Fixation der Glenoidkomponente, zur Vermeidung von inferiorem Glenoid-Notching und zur Erzielung einer optimalen Funktion ist eine möglichst physiologische Wiederherstellung der dreidimensionalen Glenoidanatomie notwendig. Um die individuellen Glenoidpathologien differenzialtherapeutisch optimal anzugehen, ist eine Klassifikation der Defekte wichtig. Hierbei ist grundsätzlich zwischen zentrischen „contained“ und exzentrischen „uncontained“ Defekten zu unterscheiden. Häufig kommen Kombinationen vor. Wichtig ist auch, den Schweregrad, die Tiefe und die dreidimensionale Orientierung des Defekts zu berücksichtigen. Daher ist präoperativ eine CT-Analyse des Glenoids notwendig. Die gewonnenen Daten sollten für eine computerassistierte Planung zur Bestimmung der optimalen Position der Glenoidbasisplatte, Art und Form des Revisionsimplantats sowie Größe und Form des Knochentransplantats benutzt werden. Die Art der Knochenspankonfiguration und -fixation sowie die Entscheidung zwischen ein- oder zweizeitigem Vorgehen hängen vom Defekttyp und von der Defektschwere ab. Bei Patienten mit guter Knochenqualität empfehlen wir die Defektrekonstruktion mit autologem Beckenkammspan. Bei technisch korrekter Spanimplantation und korrektem Protheseneinbau ist eine Integration des Knochentransplantats sowie dauerhafte Festigkeit der Glenoidkomponente mit zufriedenstellenden klinischen Ergebnissen zu erwarten. Durch den knöchernen Wiederaufbau des Defekts ist langfristig die wiederholte Versorgung mit einer inversen Glenoidkomponente einfacher möglich.

Abstract

Glenoid pathologies are one of the main indications for shoulder arthroplasty revisions. In most cases, the glenoid bone defect is associated with insufficiency of the rotator cuff, so that only reverse total shoulder arthroplasty can be considered as a revision implant. For stable permanent fixation of the reverse glenoid component, to avoid inferior glenoid notching, and to achieve optimal function, physiological restoration of three-dimensional glenoid anatomy is necessary. In order to approach the individual glenoid pathologies in a differentiated and optimal manner, it is important to classify the defects. A basic distinction must be made between centric contained and eccentric uncontained defects. Combinations often occur. It is also important to consider the severity, depth, and three-dimensional orientation of the defect. Therefore, a CT analysis of the glenoid is essential preoperatively. The data obtained should serve as the basis for computer-assisted planning to determine the optimal position of the glenoid baseplate and the type and shape of the bone graft for the reconstruction. For patients with good bone quality, we recommend defect reconstruction with autologous iliac crest. The type of graft configuration and fixation and the decision between a one- and two-stage procedure depend on the type and severity of the defect. With technically correct reconstruction and proper prosthesis implantation, sufficient integration of the bone graft and durable fixation of the glenoid component can be expected with satisfactory clinical results. After bony reconstruction of the defects, repeated treatment with a reverse arthroplasty is possible in the long term in the event of renewed glenoid problems.

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Abbreviations

C‑Defekt:

Zentrischer „contained“ Defekt

E‑Defekt:

Exzentrischer „uncontained“ Defekt

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  1. Zentrum für Orthopädie, Unfallchirurgie und Sportmedizin, München Klinik Bogenhausen, Englschalkingerstr. 77, 81925, München, Deutschland

    Ludwig Seebauer

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L. Seebauer ist als Consultant in beratender Funktion für Depuy Synthes Inc. Ltd. Leeds UK tätig und bezieht Lizenzgebühren von dieser Firma.

Für diesen Beitrag wurden vom Autor keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Seebauer, L. Knöcherne Glenoidrekonstruktion in der Revisionsendoprothetik. Orthopädie 52, 109–121 (2023). https://doi.org/10.1007/s00132-022-04336-4

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