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Therapie der Rotatorenmanschettenruptur – ein Evidenzupdate

  • Eduard BuessEmail author
Übersicht

Zusammenfassung

Rupturen der Rotatorenmanschette (RM) zeigen eine starke Altersabhängigkeit mit ansteigender Prävalenz auf bis zu 62 % bei den über 80-Jährigen. In einem großen unselektionierten Kollektiv wurden sonographisch 21 % Komplettrupturen entdeckt, die Prävalenz asymptomatischer Rupturen betrug 13 %. Als Studienmodell für den natürlichen Krankheitsverlauf eignen sich Ultraschalllongitudinalstudien von asymptomatischen RMR (RM-Rupturen) bei Patienten mit einer symptomatischen kontralateralen Schulter. Die meisten degenerativen Rupturen entstehen 15 mm dorsal der Bizepssehne, weniger als ein Drittel betreffen auch den ventralen Sehnenstreifen, das sog. „anterior cable“. Da diese Fälle zu schnellerer Muskeldegeneration neigen, ist bei Verletzung des „anterior cable“ die Operationsindikation eher zu stellen. Etwa die Hälfte der degenerativen Rupturen vergrößern sich über 5 Jahre; Komplettrupturen haben eine viel höhere Wahrscheinlichkeit der Vergrößerung und fettigen Muskelinfiltration als Partialrupturen. Der Referenzpunkt für eine wahrscheinlich erfolgreiche Heilung liegt bei einer Größe von max. 2 cm, einem Goutallier-Stadium von max. 2 und einem Alter von unter 69 Jahren. Die RMR ist – obwohl teuer – für die Gesamtgesellschaft kosteneffektiv, v. a. auch durch die Reduktion der indirekten Krankheitskosten. Einigkeit besteht, dass die meisten traumatischen Komplettrupturen operiert werden sollten, hingegen ist die Behandlung von degenerativen Läsionen umstritten. Level-I-Studien fanden im Vergleich operativ vs. konservativ nur kleine Unterschiede. Der arthroskopische Repair ist heute der Goldstandard. Zweireihige Rekonstruktionen ergeben höhere Heilungsraten bei klinisch geringem Unterschied zu einreihigen; ankerlose arthroskopische Techniken könnten in naher Zukunft eine Renaissance erleben.

Schlüsselwörter

Risikofaktoren Krankheitsverlauf Rekonstruktion Schulterschmerz Gesundheitsökonomie 

Abkürzungen

ASES

American Shoulder & Elbow Surgeons Score

CS

Constant Score

DR

„Double row“

EFP

„Exposed footprint“

FU

Follow-up

ISP

Infraspinatus

RM

Rotatorenmanschette

RMR

Rotatorenmanschettenruptur

SB

„Suture bridge“

SR

„Single row“

SSC

Subskapularis

SSP

Supraspinatus

VAS

Visuelle Analogskala

Treatment of rotator cuff tears—an evidence-based update

Abstract

Rotator cuff (RC) tears show a very strong association with age reaching a prevalence of up to 62% in persons over 80. Ultrasound screening in large unselected population samples has detected a prevalence of full-thickness RC tears in 21%; asymptomatic tears were found in 13%. Longitudinal ultrasound studies of asymptomatic RC tears in patients with a symptomatic contralateral shoulder are the preferred study model to follow the natural course of the disease. Most degenerative tears initiate about 15 mm posterior to the biceps, less than one third involve the anterior supraspinatus tissue known as the “anterior cable”. Loss of integrity of this slip of tendon is associated with accelerated muscle degeneration. Therefore, repair of the anterior cable is considered to be crucial. Approximately 50% of the degenerative tears will progress in size over five years, and full-thickness tears are much more likely to enlarge and develop muscle degeneration than partial-thickness tears. The cut-off point for successful healing seems to be a tear of ≤2 cm with a Goutallier stage of grade ≤2 in a patient ≤69 years. Though expensive, RC repair was found to be cost-effective for society as a whole by reducing the indirect costs especially in younger patients. There is consensus that most full-thickness traumatic tears should be treated operatively; however treatment regarding degenerative tears is still controversial. Level I evidence comparing conservative vs operative treatment of smaller degenerative tears tends to find only small differences in outcome. Operative techniques have improved rapidly over the last two decades, and arthroscopic repair is now considered the gold standard. Double-row repairs have produced higher healing rates as compared to single-row, but clinically the differences are small; anchorless arthroscopic repair techniques might experience a revival in the near future.

Keywords

Risk factors Natural history Repair Shoulder pain Health economics 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

E. Buess: Beratungstätigkeit für die Firma DePuy/Synthes/Mitek.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.Orthopädische Praxis „Shouldercare“BernSchweiz

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