Zusammenfassung
Mit der steigenden Zahl primär implantierter Schulterendoprothesen erhöht sich auch die Revisionsrate, die nach Auswertung von Metaanalysen 11,2 % bei anatomischen und 13,4 % bei inversen Implantaten beträgt. Um die Wechseloperationszahl zu senken, muss man bereits bei der Indexoperation etwaige langfristige Komplikationsmöglichkeiten bedenken und ein Implantat wählen, das modular auswechselbar ist, ohne zukünftigen Schaftausbau oder Wechsel der glenoidalen Basisplatte. Für einen Endoprothesenwechsel gibt es eine ganze Reihe von Indikationen: sekundärer Pfannenverbrauch, aseptische Lockerung, Infektionen, Rotatorenmanschettendefekt, Instabilität, Prothesenfehlstellung, mechanische Komplikationen und periprothetische Frakturen.
Da die Rate von Humerusfrakturen beim Wechsel von anatomischen Prothesen bei 12 % und von inversen Prothesen bei 30 % liegt, kommt der Humerusosteotomie ein besonderer Stellenwert zu. Unterschieden wird zwischen einfacher Schaftosteotomie, distalem Knochenfenster und transhumeraler Schaftosteotomie nach Gohlke. Die größte Schwierigkeit bei der Implantation des Revisionsschafts liegt in der passgenauen Einstellung der Prothesenhöhe, weil davon die Stabilität, Kraftentfaltung des M. deltoideus und im ungünstigsten Fall die Ausbildung einer Schultersteife abhängt.
Beim Wechsel einer anatomischen Pfanne hängt das Ergebnis ganz vom Knochendefekt ab. Zwar weisen Revisionspfannen bessere Ergebnisse als ein alleiniger Pfannenaufbau mit kortikospongiösen Spänen auf, gehen aber auch mit hohen sekundären Lockerungsraten einher. Im Revisionsfall scheinen zementfreie Revisionspfannen eine bessere Verankerungsqualität aufzuweisen als zementierte Pfannen. Beim Wechsel von Glenosphären sollte bei jeder Rekonstruktion versucht werden, die Glenosphäre mit einem inferioren Tilt, d. h. in leichter Varusstellung einzubauen, weil damit ein größerer Formschluss mit der Humeruspfanne bei mechanisch günstigerer Belastung des glenoidalen „bone stock“ resultiert.
Abstract
The increasing number of primary shoulder arthroplasty operations is correlated to an increasing revision rate of up to 11.2 % for anatomical shoulder arthroplasty and 13.4 % for reverse shoulder arthroplasty. To reduce the risk of implant revision the surgeon has to take the possibility of late complications into account for the index operation and to choose a modular implant system. Indications for revision arthroplasty are secondary glenoid wear, aseptic loosening, infections, rotator cuff deficiency, instability, implant malpositioning, mechanical complications and periprosthetic fractures. Due to the high rate of humeral fractures during revision surgery of anatomical stemmed implants (12 %) and reverse implants (30 %) osteotomy of the humerus is of particular importance. Osteotomy of the humeral shaft with a distal window or transhumeral shaft osteotomy as described by Gohlke can be used. The most demanding step during implantation of the revision implant is the accurate reconstruction of the prosthetic height because the stability, strength of the deltoid muscle and in unfavourable situations the degree of stiffness in the glenohumeral joint all depend on the prosthetic height. The result of anatomical glenoid revision surgery totally depends on the bony defect. Revision glenoid components showed better results compared to glenoid reconstruction using a corticocancellous bone graft but resulted in a higher rate of secondary loosening of the glenoid implant. Cementless glenoid revision implants seem to achieve a higher stability of bony fixation than cemented implants. Due to a better form closure with the reverse humeral implant and a mechanically more favorable loading of the glenoid bone stock, the glenosphere should be implanted with an inferior tilt in revision surgery.
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Die korrespondierende Autorin weist auf folgende Beziehung hin: Prof. Habermeyer erhält Patentlizenzen der Firma Arthrex. Dr. Petra Magosch gibt an, dass kein Interessenkonflikt besteht.
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Habermeyer, P., Magosch, P. Strategien beim Endoprothesenwechsel der Schulter. Orthopäde 42, 542–551 (2013). https://doi.org/10.1007/s00132-012-2025-5
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DOI: https://doi.org/10.1007/s00132-012-2025-5