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Arthroskopische superiore Kapselrekonstruktion mit einem 6 mm dicken azellulären dermalen Allograft bei irreparablen posterosuperioren Rotatorenmanschettenrupturen

Arthroscopic superior capsule reconstruction using a 6 mm thick acellular dermal allograft for irreparable posterosuperior rotator cuff tears

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Zusammenfassung

Operationsziel

Wiederherstellung eines stabilen glenohumeralen Rotationszentrums bei irreparablen Rupturen der posterosuperioren Rotatorenmanschette durch Implantation eines azellulären dermalen Allografts zwischen Glenoid und Humerus.

Indikationen

Irreparable posterosuperiore Rotatorenmanschettenrupturen mit niedriggradiger Defektarthropathie (Stadium 1 und 2 nach Hamada) und isolierter Pseudoparese für Flexion.

Kontraindikationen

Absolut: Infekt, Nervenschädigung (Plexus brachialis, N. axillaris), begleitende irreparable Ruptur der Subskapularissehne, anterosuperiore Subluxation des Humeruskopfes („anterosuperiorer Escape“). Relativ: Defektarthropathie ≥ Stadium 3 nach Hamada, fettige Infiltration des M. infraspinatus ≥ Grad 2 nach Goutallier, Insuffizienz des M. deltoideus, Unfähigkeit, das Rehabilitationsprogramm einzuhalten, mangelnde Compliance.

Operationstechnik

Arthroskopische Fixation eines 6 mm dicken azellulären dermalen Allografts mit 3 Fadenankern am oberen Glenoidrand und einer Doppelreihenkonstruktion am Tuberculum majus. Dorsaler und ventraler Intervallverschluss mit Seit-zu-Seit-Nähten.

Weiterbehandlung

Abduktionsorthese für 6 Wochen mit passiver Mobilisation. Ab 7. Woche aktive, belastungsfreie Mobilisation und nach 12 Wochen Belastungsaufbau.

Ergebnisse

Zwischen April 2019 und September 2020 wurde bei 15 Patienten (5 Frauen und 10 Männer) eine arthroskopische superiore Kapselrekonstruktion mit einem 6 mm dicken azellulären dermalen Allograft zur Behandlung einer irreparablen Ruptur der posterosuperioren Rotatorenmanschette durchgeführt.

Nach einem durchschnittlichen Nachuntersuchungszeitraum von 15,4 ± 5,5 Monaten zeigte sich eine signifikante Verbesserung der aktiven Flexion (102° ± 37°präop vs. 143° ± 24°postop; P = 0,001; 95 % CI: 19,6–63,7), des ASES score (45,5 ± 16,1präop vs. 68,2 ± 17,4postop; P < 0,001; 95 % CI: 12,9–33,7) und DASH score (57,2 ± 18,6präop vs. 22,0 ± 17,4postop; P < 0,001; 95 % CI: −46,0–−24,7), verbunden mit einer signifikanten Schmerzreduktion (4,5 ± 2,0präop vs. 2,5 ± 2,1postop; P = 0,001; 95 % CI: −3,2–−1,1). Revisionspflichtige Komplikationen traten nicht auf.

Abstract

Objective

Implantation of an acellular dermal allograft between glenoid and humerus to restore a stable glenohumeral center of rotation in cases of irreparable posterosuperior rotator cuff tears.

Indications

Irreparable posterosuperior rotator cuff tears with low-grade cuff tear arthropathy (Hamada grade 1 and 2) and isolated pseudoparesis for flexion.

Contraindications

Absolute: Infection, nerve lesions (brachial plexus, axillary nerve), concomitant irreparable subscapularis tendon tear, anterosuperior subluxation of the humeral head (“anterosuperior escape”). Relative: Cuff tear arthropathy ≥ Hamada grade 3, fatty infiltration of the infraspinatus muscle ≥ Goutallier grade 2, deficiency of the deltoid muscle, inability to adhere to the rehabilitation program, poor compliance.

Surgical technique

Arthroscopic fixation of a 6 mm thick acellular dermal allograft with three suture anchors at the superior glenoid rim and a double-row construct at the greater tuberosity. Dorsal and ventral interval closure with side-to-side sutures.

Postoperative management

Abduction brace for 6 weeks with passive mobilization. Active motion exercises are commenced at 6 weeks with progression to strengthening exercises after 12 weeks.

Results

Between April 2019 and September 2020, 15 patients (5 women and 10 men) underwent arthroscopic superior capsule reconstruction using a 6 mm thick acellular dermal allograft for treatment of irreparable posterosuperior rotator cuff tears. After a mean follow-up of 15.4 ± 5.5 months, there was a significant improvement in active flexion (102° ± 37°preop vs. 143° ± 24°postop; P = 0.001; 95% CI 19.6–63.7), ASES score (45.5 ± 16.1preop vs. 68.2 ± 17.4postop; P < 0.001; 95% CI; 12.9–33.7) and DASH score (57.2 ± 18.6preop vs. 22.0 ± 17.4postop; P < 0.001; 95% CI; −46.0 to 24.7), along with significant pain reduction (4.5 ± 2.0preop vs. 2.5 ± 2.1postop; P = 0.001; 95% CI; −3.2 to 1.1). There were no complications requiring revision surgery.

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Authors and Affiliations

  1. Abteilung für Sportorthopädie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland

    Lukas N. Muench, Jonas Pogorzelski &  Bastian Scheiderer

Authors
  1. Lukas N. Muench
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  2. Jonas Pogorzelski
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  3. Bastian Scheiderer
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Correspondence to Bastian Scheiderer.

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Interessenkonflikt

L.N. Muench, J. Pogorzelski und B. Scheiderer geben an, dass kein Interessenkonflikt besteht.

Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Herausgeber

Andreas B. Imhoff, München

Zeichnungen

Rüdiger Himmelhan, Mannheim

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Muench, L.N., Pogorzelski, J. & Scheiderer, B. Arthroskopische superiore Kapselrekonstruktion mit einem 6 mm dicken azellulären dermalen Allograft bei irreparablen posterosuperioren Rotatorenmanschettenrupturen. Oper Orthop Traumatol 34, 13–20 (2022). https://doi.org/10.1007/s00064-021-00758-z

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