Zusammenfassung
Operationsziel
Rekonstruktion der superioren Kapsel bei irreparablem Riss der Supraspinatussehne.
Indikationen
Irreparabler Supraspinatussehnenriss; zentrierter Humeruskopf; weitestgehend intakter Knorpel; weitestgehend intaktes transversales Kraftpaar.
Kontraindikationen
Dezentrierter Humeruskopf; Omarthrose/Defektarthropathie; irreparable ausgedehnte anterosuperiore und posterior-superiore Manschettenrisse.
Operationstechnik
Die arthroskopische superiore Kapselrekonstruktion wird in Beach-chair-Lagerung durchgeführt. Zuerst erfolgt das Anfrischen der Insertion der Supraspinatussehne und das Anfrischen kranial am Glenoid. Nun bestehen, je nach Zustand der langen Bizepssehne, 2 unterschiedliche Varianten. Variante 1: Bei einer vorhandenen Bizepssehne erfolgt eine Bizepssehnentenodese an das Tuberculum majus. Hierbei wird die lange Bizepssehne mittels eines Fadenankers zentral an der Insertionsstelle der Supraspinatussehne fixiert. Variante 2: Bei einer nichtvorhandenen oder stark tendinopathischen langen Bizepssehne erfolgt das Setzen eines PushLock®-Ankers (Arthrex, Inc. Naples, FL, USA) mit einem FiberTape® (Arthrex, Inc. Naples, FL, USA) beladen, zentral an der Glenoidoberseite. Nun erfolgt die eigentliche superiore Kapselrekonstruktion. Es werden jeweils 2 Fadenanker am Glenoid und 2 SwiveLock®-Anker (Arthrex, Inc. Naples, FL, USA) jeweils mit einem FiberTape® beladen am Tuberculum majus gesetzt. Die Fäden werden nach extraartikulär geführt, die Abstände zwischen den Ankern werden gemessen, und somit wird die Größe des Transplantats bestimmt, welches dann zugeschnitten wird. Das Graft wird mit den jeweiligen Fäden an den jeweiligen Ecken durchstochen und über die Fäden der Anker am Glenoid nach intraartikulär gezogen. Bei guter Position des Grafts werden die Fäden der glenoidalen Anker verknüpft. Lateral wird das Graft im Sinne einer knotenlosen Doppelreihennaht fixiert. Die beiden Fadenenden des Tapes, des zuvor am Glenoidrand gesetzten PushLock®-Ankers (Arthrex, Inc. Naples, FL, USA) werden mit in die laterale Reihe aufgenommen und über das Graft abgespannt. Dann erfolgen noch eine subakromiale Dekompression sowie Seit-zu-Seit-Nähte zur Infraspinatussehne.
Nachbehandlung
Der Arm wird in einem Gilchrist-Verband für 6 Wochen ruhiggestellt, zu dieser Zeit beginnt bereits die passiv assistierte Physiotherapie. Nach 6 Wochen kann mit der aktiven Bewegungstherapie begonnen werden.
Ergebnisse
Zwischen 2017 und 2019 wurden 11 Patienten mittels der singulären superioren Kapselrekonstruktion versorgt. Das Vorgehen mit Augmentation entspricht unserem neuen Behandlungsalgorithmus, diesbezüglich werden Fallbeispiele präsentiert. Von den Patienten mit singulärer Kapselrekonstruktion konnten 9 Patienten nach einem durchschnittlichen Nachuntersuchungszeitraum von 18 Monaten eingeschlossen werden. Eine statistisch signifikante Reduktion der Schmerzen (6,3 → 2), eine postoperativ gute Anteversion (Durchschnitt 138°, 56 STD), Außenrotation (Durchschnitt 37°, 21 STD) sowie gute ASES (Durchschnitt 76,5, 18 STD), DASH (Durchschnitt 17,8, 14 STD) und Constant-Scores (Durchschnitt 64,6, 25 STD) konnten erreicht werden.
Abstract
Objectives
Reconstruction of the superior capsule for treatment of irreparable supraspinatus tendon tears.
Indications
Irreparable supraspinatus tendon tear; centered humeral head; largely intact cartilage; largely intact transversal “force-couple”.
Contraindications
Decentered humeral head; osteoarthritis of the glenohumeral joint/cuff tear arthropathy; irreparable anterosuperior and posterosuperior cuff tears.
Surgical technique
Arthroscopic superior capsule reconstruction (SCR) is performed in beach-chair position. At first the bone bed of the glenoid and the insertion of the supraspinatus tendon are prepared using a bone burr. Now, depending on the integrity of the long biceps tendon, two options are possible. Option 1: In the case of an existing long biceps tendon, a biceps tendon tenodesis to the greater tubercle is performed. Therefore, the long head of the biceps is fixed central to the former insertion of the supraspinatus tendon, using a suture anchor. Option 2: In the case of a nonexisting or degeneratively modified long biceps tendon, a PushLock® anchor (Arthrex, Inc. Naples, FL, USA) loaded with a FiberTape® (Arthrex, Inc. Naples, FL, USA) is placed centrally onto the glenoid. Now, the actual superior capsule reconstruction is completed. Two suture anchors are placed at the glenoid and two SwiveLock® anchors, each loaded with a FiberTape®, (Arthrex, Inc. Naples, FL, USA) are placed at the footprint of the supraspinatus tendon at the greater tubercle. The tapes are shuttled extra-articularly and the graft size is evaluated by measuring the distance between the anchors. The graft is customized to that size and armed with the tapes. Using the tapes of the glenoidal anchors, as tension ropes, the graft is placed intra-articularly. Medially the sutures are tied and laterally the graft is fixed in a knotless lateral row manner. The tails of the tape, of the glenoidal PushLock® (Arthrex, Inc. Naples, FL, USA) anchor are fixed within the lateral row and are tensioned above the graft. Afterwards side-to-side sutures to the infraspinatus and a subacromial decompression are completed.
Postoperative management
The arm is placed in a sling for 6 weeks, afterwards active physiotherapy begins. Passive-assisted physiotherapy is started on postoperative day 1.
Results
Between 2017 and 2019, 11 patients were treated with SCR. As the combined procedure is our new treatment algorithm, case studies will be presented. For this study, 9 patients treated with singular SCR, with a mean follow-up of 18 months, were recruited. A statistically significant reduction of pain (VAS 6.3 → VAS 2), a good postoperative forward flexion (mean 138°; 56 standard deviation [SD]), and external rotation (mean 37°; 21 SD) were measured. A mean ASES of 76.5 (18 SD) a mean DASH of 17.8 (14 SD) and a mean Constant score of 64.6 (25 SD) were achieved.
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F. Rittenschober und R. Ortmaier geben an, dass kein Interessenkonflikt besteht.
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Andreas B. Imhoff, München
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Rüdiger Himmelhan, Mannheim
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Rittenschober, F., Ortmaier, R. Arthroskopische Augmentationstechniken der superioren Kapselrekonstruktion. Oper Orthop Traumatol 34, 21–33 (2022). https://doi.org/10.1007/s00064-021-00757-0
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DOI: https://doi.org/10.1007/s00064-021-00757-0