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Kontroversen in der Behandlung von Rupturen der Rotatorenmanschette

Konservativ oder operativ, offen oder arthroskopisch?

Controversies in the therapy of rotator cuff tears

Operative or nonoperative treatment, open or arthroscopic repair?

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Zusammenfassung

Rupturen der Rotatorenmanschette stellen eine häufige Schulterpathologie dar, welche zu einer Störung der Schulterfunktion mit Einschränkungen der Lebensqualität führen kann. Darüber hinaus ist sie mit hohen direkten und indirekten Kosten verbunden. Neben konservativen Therapieoptionen stehen verschiedene Operationsverfahren zur Rekonstruktion der Rotatorenmanschette zu Verfügung. Hierbei ist die richtige therapeutische Strategie für die Behandlung der Rotatorenmanschettenruptur von fundamentaler Bedeutung.

Die konservative Therapie der Ruptur der Rotatorenmanschette stellt eine mögliche Alternative bei Patienten mit kleinen, inkompletten Rupturen ohne fettige Atrophie und Retraktion der Sehne, welche nur geringe Beschwerden haben, sowie älteren Patienten mit einem geringen funktionellen Anspruch dar. Weiterhin sollte die operative Therapie nach frustraner konservativer Therapie über einen Zeitraum von 3–6 Monaten bei entsprechendem Leidensdruck erwogen werden. Darüber hinaus ist sie das Mittel der Wahl beim Vorliegen eines Risses der Rotatorenmanschette beim jungen Patienten mit hohem funktionellen Anspruch, bei Patienten in körperlich belastenden Berufen sowie Patienten mit größerer Ruptur oder bereits Atrophie bzw. Retraktion der Sehne.

Die arthroskopische Therapie stellt aufgrund der besseren Kosmetik, den Vorteilen in Bezug auf Begleitpathologien, den geringeren postoperativen Beschwerden, des geringeren Risikos einer postoperativen Schultersteife sowie der gezielteren Adhäsiolyse, mittlerweile den Goldstandard dar. Mit der arthroskopischen Versorgung lassen sich jedoch die Ergebnisse im Vergleich zu offenen Verfahren nicht verbessern. Auch aufgrund der aktuellen Vergütungssituation ist daher die offene Therapie der Rotatorenmanschettenruptur immer noch eine praktikable Alternative.

Abstract

Rotator cuff tears are a common cause of shoulder pain that may lead to severe impairment of shoulder function with significant limitation of the quality of life. Furthermore, they are associated with high direct and indirect costs.

Conservative therapy and various surgical procedures for rotator cuff repair are all possible treatment options. Therefore, the correct treatment for a symptomatic rotator cuff tear is important.

The conservative therapy may be considered as an alternative treatment option for a symptomatic rotator cuff tear in patients with small or incomplete tears with no fatty atrophy or tendon retraction, with only slight pain, and in older patients with few functional demands. Surgical treatment is recommended after failed conservative treatment lasting 3–6 months, with the corresponding psychological strain. Moreover, surgical treatment should be considered as a primary treatment option for a symptomatic rotator cuff tear in young patients with high functional demands, patients with a high level of physical strain in their jobs, large tears, and tears where there is already significant muscle atrophy or tendon retraction.

Arthroscopic treatment is considered to be the gold standard because of the better cosmetic results and treatment of concomitant pathological conditions, the lower levels of postoperative pain, the potentially lower risk of shoulder stiffness, and more focused adhesiolysis. However, arthroscopy does not improve clinical results. Because of the current financial situation, however, open rotator cuff repair is still a viable alternative.

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  1. Klinik für Orthopädie und Orthopädische Chirurgie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrberger Straße, Gebäude 37-38, 66421, Homburg (Saar), Deutschland

    O. Lorbach

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Lorbach, O. Kontroversen in der Behandlung von Rupturen der Rotatorenmanschette. Orthopäde 45, 112–117 (2016). https://doi.org/10.1007/s00132-015-3212-y

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