Patch-Augmentation in der Re-Insertionschirurgie der Rotatorenmanschette bei älteren Patienten

 

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Zusammenfassung

Hintergrund: Massive Rupturen (2 und mehr Sehnen) der Rotatorenmanschette haben vor allem bei älteren Patienten eine sehr schlechte Prognose. Zur Senkung der Rerupturrate wird seit einigen Jahren in der orthopädischen Praxis die Verstärkung der Nahtstelle durch Patches (Augmentation) angewandt.

Material und Methoden: In einer klinischen Studie (Operationen von 2005 bis 2011) testeten wir Patches aus unterschiedlichen Materialien auf Verbesserung der Integrität der Rotatorenmanschette bei 89 Patienten (63 m/26 w), die im Schnitt das Pensionsalter überschritten hatten. Hierzu wurden in „Parachute-Technik“ Graft Jacket, ein biologisches Matrixmaterial humanen Ursprungs, Artelon, ein sehr langsam abbauender Polyurethanharnstoff-Patch sowie Restore, ein orthobiologisches Implantat, in arthroskopischer OP-Technik zusätzlich über die Sehnen-Knochen-Naht gespannt und vernäht.

Ergebnisse: Über alle verwendeten Patches hinweg konnte bei primärer Rekonstitution in 3 von 4 Fällen die Rotatorenmanschette erfolgreich komplett rekonstituiert werden. In der Revisionschirurgie lag die Quote bei knapp 2 Dritteln etwas niedriger. Inerte, nicht resorbierende Patches zeigen in der Primärversorgung die deutlich besten Resultate. Die klinischen Scores (CS) erreichten bei allen operierten Patienten rund 80 % der Normwerte (Maximalwerte), die subjektiven Schulterwerte nach 6 Monaten über 80 % und nach 3 Jahren über 90 % der Normalwerte. Es kam zu keinen gravierenden Nebenwirkungen.

Schlussfolgerung: Vor allem Sehnen mit reduzierten mechanischen Eigenschaften, wie sie bei älteren Patienten und in der Revisionschirurgie häufig anzutreffen sind, profitieren von der Verstärkung und Entlastung der empfindlichen Naht-Sehnen-Schnittstelle. Die Erfolgsraten von bis zu 87,5 % im Fall von Graft Jacket bei primärer Versorgung der Rotatorenmanschette sind sehr ermutigend (vergleichbare Studien und Metastudien in diesem Bereich zeigen Erfolgsraten bei gravierenden Rupturen der Rotatorenmanschette von 43 bis 59 %) und verweisen auf eine Entwicklung hin zu immer besseren, intelligenteren Patch-Materialien in Bezug auf Fließspannung, Festigkeit und Grenzlast.

Abstract

Background: Massive rotator cuff tendon tears have a poor clinical prognosis. This holds especially true in older patients and after revision surgery. In order to reduce tears and increase long term shoulder parameters, patches made of a variety of materials have been applied to reinforce sutures in current orthopaedic practice.

Material and Methods: In a clinical study on rotator cuff surgery from 2005 to 2011 (date of surgical intervention), we tested the efficacy of three different commercial patches, with 89 patients (63 m/26 w) enrolled with a mean age of over 60. Graft Jacket, a regenerative stable human tissue scaffold, Artelon, a slow-resorbable polyurethane-urea patch and Restore, an orthobiological degradable graft, were arthroscopically implanted in order to augment the fragile tendon-bone interface after massive tears of 2 to 3 tendons (supraspinatus and/or infraspinatus and/or subscapularis).

Results: An overall repair integrity score of 75 % was achieved in primary rotator cuff surgery and of 65 % in revision surgery with either non- or slowly resorbable patches outperforming the degradable material. This effect is more marked after primary surgery. CS values indicate overall patient recovery at 6 months of 81.43 vs. 47.29 for Graft Jacket, 81.34 vs. 46.18 for Artelon and 78.45 vs. 41.93 for Restore. Subjective shoulder value (SSV) at 3 years increased to 9.11 vs. 4.32 for Graft Jacket, 9.31 vs. 3.53 for Artelon and 9.45 vs. 2.9 for Restore. No severe adverse affects were encountered.

Conclusions: Tendons with reduced mechanical characteristics can greatly profit from patch augmentation. This holds especially true for older patients and in revision surgery. The success rate of our patch studies was up to 87 % for Graft Jacket in primary rotator cuff surgery and a minimum of 58.3 % for Restore in pure revision surgery (comparable studies/metastudies on massive rotator cuff tear repair success rates range from 43 to 59 %). This paves the way for a continued search for better and more intelligent materials. Yield load, stiffness and ultimate load will probably improve further in the very near future.

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