Gohlke Frank, Berner Arne, Abdelkawi Ayman
Klinik für Orthopädie, Unfallchirurgie, Schulter- und Ellenbogenchirurgie und Endoprothetik, Rhön-Klinikum, Campus Bad Neustadt/Saale, Salzburger Leite 1, 97616, Bad Neustadt/Saale, Deutschland.
Orthopadie (Heidelb). 2023 Feb;52(2):98-108. doi: 10.1007/s00132-022-04335-5. Epub 2023 Jan 18.
Revision shoulder arthroplasty is mainly performed with reverse TSA and should consider proper adjustment of the length and the amount of bone loss in humeral reconstruction. Whilst epi-/metaphyseal bone loss can mostly be compensated easily by stemmed standard implants, advanced bone loss exceeding 2° requires the support of longer revision stems.
Cementless fixation in the intact diaphyseal humerus is recommended in bone loss exceeding 2°, preferably with modular revision systems, because cemented reverse revision stems have higher loosening rates in the mid to long-term follow-up. In cases of advanced bone loss 3°-4° (more than 6-7 cm), structural humeral allografts should be considered to prevent instability and early loosening. Unfortunately, the access to fresh frozen allografts is very limited due to regulation of the German government in contrast to the situation in the US or Switzerland. Reverse tumor arthroplasty is an option with a higher complication rate and inferior function even when polyester mesh is used for ingrowth of soft tissues.
In bone loss 4°-5° the minimal anchorage length is mostly critical due to the curvature of the medullary canal. The fixation of a revision stem is only possible when at least 2-3 widths of the diaphyseal diameter are available. Custom-made implants with flanges or distal locking screws, or bipolar tumor arthroplasty may be required. Additionally, strut allografts can be useful to achieve stable fixation. Two-stage biological reconstruction in impaction-bone-graft or the Masquelet technique are rarely used as a salvage procedure.
翻修肩关节置换术主要采用反式全肩关节置换术（reverse TSA），在肱骨重建时应适当调整长度并考虑骨量丢失情况。虽然干骺端/骨骺端骨量丢失大多可通过带柄标准植入物轻松补偿，但超过2°的严重骨量丢失则需要更长的翻修柄来支撑。
对于超过2°的骨量丢失，建议在完整的肱骨干中采用非骨水泥固定，最好使用模块化翻修系统，因为骨水泥型反式翻修柄在中长期随访中松动率较高。对于3° - 4°（超过6 - 7厘米）的严重骨量丢失情况，应考虑使用结构性肱骨同种异体骨移植以防止不稳定和早期松动。遗憾的是，与美国或瑞士的情况相比，由于德国政府的规定，获取新鲜冷冻同种异体骨的途径非常有限。即使使用聚酯网促进软组织长入，反式肿瘤关节成形术也是一种并发症发生率较高且功能较差的选择。
在4° - 5°的骨量丢失情况下，由于髓腔的曲率，最小锚固长度大多至关重要。只有当至少有2 - 3个骨干直径宽度可用时，才有可能固定翻修柄。可能需要带凸缘或远端锁定螺钉的定制植入物，或双极肿瘤关节成形术。此外，支撑同种异体骨移植有助于实现稳定固定。冲击植骨或Masquelet技术中的两阶段生物重建很少用作挽救手术。
