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Knöcherne Rekonstruktionsverfahren bei anteroinferioren Glenoiddefekten und vorderer Schulterinstabilität

Indikation, Graftwahl, Operationstechniken, Ergebnisse und Komplikationen

Bony reconstruction procedures for anteroinferior glenoid defects and anterior shoulder instability

Indication, graft choice, surgical techniques, outcomes, and complications

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Zusammenfassung

Vordere Schulterluxationen führen häufig zu knöchernen Defekten des anteroinferioren Glenoids und können in einer Schulterinstabilität resultieren. Substantielle knöcherne Defekte reduzieren die Konkavität des Glenoids und die glenohumerale Kontaktfläche. Häufig treten auch bipolare knöcherne Defekte auf. Für Defekte einer „kritischen“ Größe von > 20 % der Glenoidbreite ohne ein refixierbares Fragment, Rezidivinstabilitäten, insuffiziente Weichteilstrukturen oder relevante Hill-Sachs-Defekte kommen knöcherne Rekonstruktionsverfahren zum Einsatz. Hier lassen sich zwei verschiedene Techniken unterscheiden: der Korakoidtransfer und der Transfer freier Knochentransplantate. Modifikationen dieser Operationstechniken unterscheiden sich bezüglich des operativen Zugangsweges, Graftwahl und Graftfixierung. Aktuelle Übersichtsarbeiten beschreiben für beide Methoden vergleichbare gute klinische Ergebnisse mit adäquater Schulterstabilität und früher Rückkehr zur sportlichen Aktivität. Freie Knochentransplantate ermöglichen eine flexiblere Graftpräparation bezüglich Form und Größe und dadurch eine vermeintlich anatomische Rekonstruktion. Die Latarjet-Technik weist biomechanisch eine potenziell höhere Stabilität durch den sog. „Sling-Effekt“ der Conjoint-Tendon auf. Neuere Techniken verwenden arthroskopische Zugänge sowie nicht-rigide Fixationstechniken. Arthroskopische Verfahren führen zu einer geringeren Invasivität, schnelleren Rehabilitation, Identifikation und Mitbehandlung von Begleitpathologien sowie, durch die Verwendung von nicht-rigiden Fixationstechniken, zu einer potenziellen Reduzierung der implantatbedingten Komplikationen.

Abstract

Anterior shoulder dislocations may result in bony defects of the anteroinferior glenoidal rim and consecutive anterior shoulder instability. Moreover, substantial bony defects reduce the glenoidal concavity and the glenohumeral contact area. Bipolar defects are also frequently seen. Bony reconstruction procedures are recommended for insufficient soft tissue structures, revision instability procedures, relevant Hill–Sachs defects, and initial “critical” bone defect sizes > 20% of the glenoidal width without a refixable bony fragment. The main procedures can be divided into the coracoid transfer and free bone grafting procedures. Several modifications of these procedures which differ regarding surgical approach, graft choice, type, and orientation of graft fixation have been described. The current literature shows comparable results for both techniques with good clinical outcomes, stable shoulder function and early return to sporting activities. Free bone grafts allow an almost anatomic reconstruction with flexible graft preparation concerning shape and size. Biomechanically the Latarjet procedure provides higher stability due to the so-called “sling effect” of the conjoint tendon. Newer techniques that use arthroscopic approaches and nonrigid fixation are less invasive, provide faster rehabilitation, allow identification and treatment of concomitant pathologies, and may reduce implant-associated complications by using nonrigid fixation techniques.

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Authors and Affiliations

  1. Klinik für Orthopädie und Orthopädische Chirurgie, UKS – Universitätsklinikum des Saarlandes, Kirrberger Straße 100, Gebäude 37, 66421, Homburg, Deutschland

    Matthias Brockmeyer

  2. Abteilung für Schulterchirurgie und Sporttraumatologie, Schön-Klinik Lorsch, Wilhelm-Leuschner-Straße 10, 64653, Lorsch, Deutschland

    Olaf Lorbach

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  1. Matthias Brockmeyer
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Brockmeyer, M., Lorbach, O. Knöcherne Rekonstruktionsverfahren bei anteroinferioren Glenoiddefekten und vorderer Schulterinstabilität. Obere Extremität 17, 221–227 (2022). https://doi.org/10.1007/s11678-022-00712-w

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