Schliessen
Zum Hauptinhalt springen

Zweitmeinung bei Schulterarthroskopie

 

 

Schulterschmerzen sind ein häufiges Problem in der orthopädischen Sprechstunde. 

Acht Prozent aller Verletzungen des Menschen betreffen das Schultergelenk. 65 Prozent aller Menschen haben mit 80 Jahren einen Riss der Rotatorensehnen.90 Prozent aller Menschen klagen mindestens einmal im Leben über Schulterschmerzen. Operation oder nichtoperative Therapie?

Einen Überblick über das Thema Zweitmeinung bei Schulterschmerz gibt der Bayreuther Orthopäde und Unfallchirurg  Professor Dr. Klaus Fritsch der  sich u.a. auf die operative Therapie von Schultererkrankungen spezialisiert hat, und anerkannter Arzt für Zweitmeinungen bei arthroskopischen Schulteroperationen ist.

 

Die Operationszahlen in Deutschland haben sich zwischen 2005 und 2015 deutlich erhöht. Wobei die Operationen am Bewegungsapparat sich sogar um 48% erhöht haben.       

Dies könnte zum Bespiel an verbesserten Operationsmethoden liegen, am vermehrten Bedarf an solchen Operationen, eventuell an der Zunahme des Durchschnittsalter der Bevölkerung, aber auch daran, dass die Indikation für bestimmte Operationen großzügig gestellt werden. Risiko und Nutzen einer Operation müssen dabei immer im Vergleich zu einer alternativen nichtoperativen Therapie abgewogen werden. Gerade wegen der Komplexität vieler Indikationen bietet eine Zweitmeinung Patienten eine Unterstützung in ihrer Entscheidungsfindung, da es teilweise zu Diskrepanzen in der Indikationsstellung durch unterschiedliche Ärzte kommen kann. Die gesetzliche Krankenversicherungbietet Patienten die Möglichkeit eine Zweitmeinung einzuholen.

Zweitmeinungen sind in bestimmten Bereichen der Medizin sehr häufig. So ist zum Beispiel die Teilnahme an interdisziplinären Tumorkonferenzen und Röntgenbesprechungen ein wichtiger Bestandteil der klinischen Radiologie. Diese gemeinsamen Fallbesprechungen sprechen Empfehlungen zur optimalen Therapie aus, also Entscheidungen mit großer Tragweite. In Studien konnte auch gezeigt werden, dass in hochspezialisierten Bereichen wie etwa der Neuroradiologie oder der Kinderradiologie die Zweitmeinungen einen erheblichen Informationszugewinn bringen und häufig die Diagnose und Therapie ändern. Ähnliches gilt u.a. für Zweitmeinungen bei der Beurteilung von Schnittbildern von Tumoren in der Pathologie.

Bei planbaren medizinischen Eingriffen zweifelt die Hälfte der Patienten am Sinn der Operation. Allerdings holt sich nur ein Viertel der Menschen wirklich die zwei­te Meinung eines Arztes ein. Das geht aus einer Umfrage hervor, die im März 2019 als Onlinebefragung durchgeführt wurde, und im Deutschen Ärzteblatt veröffentlicht wurde. Demnach würden 65 Prozent der Befragten eine Zweitmeinung einholen, wenn bei ihnen ein planbarer medizinischer Eingriff bevorstehen würde. Vor allem 72 Prozent der Menschen zwischen 40 und 49 Jahren gaben an, dass sie eine Zweitmeinung wünschen.Junge Menschen zwischen 18 und 29 Jahren gaben mit nur 58 Prozent an, an einer zweiten Meinung interessiert zu sein. Sie waren in der Befragung am wenigsten kri­tisch gegenüber der Arztdiagnose eingestellt.

Eine andere Studie die in diesem Jahr veröffentlicht wurde, konnte bei 170 orthopädischen Patienten zeigen, dass die Zweitmeinung nur eine von drei Therapieempfehlungen der Erstmeinung bestätigen konnte. In der Zweitmeinung wurden häufig Schmerztherapie und Physiotherapie empfohlen, obwohl in der Erstmeinung meist eine OP-Empfehlung ausgesprochen wurde.

Zweite Meinungen spielen zunehmend in der arthroskopischen Schulterchirurgie eine Rolle. Die Anzahl der durchgeführten Schulterarthroskopien in Deutschland hat in den letzten Jahren deutlich zugenommen. Seit diesem Jahr wird von der gesetzlichen Krankenversicherung auch das Einholen von Zweitmeinungen bei Schulterarthroskopien übernommen, vorausgesetzt es handelt sich nicht um verletzungsbedingte eilige Eingriffe.

Denn der größte Teil der Schulterschmerzen läßt sich sehr gut nichtoperativ behandeln. Es handelt sich meist um Überlastungen und haltungsbedingte Schmerzen, die sehr gut mit Physiotherapie und Schmerztherapie zu kurieren sind. Die meisten Schulterschmerzen werden vom Patienten eigentlich als seitliche Oberarmschmerzen empfunden. Dieser seitliche Schulterschmerz stammt meist aus dem Bereich unterhalb der knöchernen Schulterhöhe (Acromion). Er verstärkt sich beim seitlichen Heben des Armes und führt vor allem zu nächtlichen Schmerzen. Die Patienten müssen oft das Kopfteil im Bett höher stellen, oder nachts aufstehen, um den Schmerz zu lindern. Dabei ist es vom Schmerz her schlecht zu unterscheiden, welche Struktur in diesem Raum unter der Schulterhöhe betroffen ist. Ursache kann ein Sehnenriss sein, der Schleimbeutel, Kalk oder eine Engstelle zwischen Oberarmkopf und Schulterhöhe. Die Engstelle nennt sich auch „subacromiales Impingement“. Dabei wird die Sehnengruppe der Rotatorenmanschette gequetscht, und der direkt unter dem Acromion liegende Schleimbeutel. Die Mehrzahl dieser Verengungen ist haltungsbedingt, und lässt sich durch Krankengymnastik und Medikamente gut therapieren. Ein weit verbreiteter Irrtum ist es zu glauben, dass ein gebogenes oder hakenförmiges Acromion immer operativ beseitigt werden muss. Die meisten dieser Acromionformen sind nicht krankhaft, sondern lediglich Varianten. Wenn es zu einer Schädigung der Rotatorenmanschette kommt, ist jedoch häufig ein operatives Vorgehen nicht vermeidbar. Diese Sehnenrisse können im Lauf der Zeit an Größe zunehmen, und dadurch zu vermehrten Schmerzen und Bewegungseinschränkung führen, und sind dann ab einer bestimmten Größe auch nicht mehr rekonstruierbar. Dabei handelt es sich allermeistens um einen langsamen Prozess, der sich über Monate hinzieht. Eine eventuell anstehende Operation ist deswegen in Ruhe planbar. Bei der sogenannten Kalkschulter sitzt der Kalk in der Rotatorenmanschette, und kann ebenfalls zu Schmerzen führen, die in die Oberarmaußenseite ausstrahlen. Es handelt sich dabei um ein Krankheitsbild, das sich in aller Regel selbst begrenzt, ohne dass operativ eingegriffen werden muss. Bei lang anhaltenden Schmerzen, die sich nicht anders beherrschen lassen, kann der Kalk arthroskopisch entfernt werden.

Allgemein bekannt geworden ist eine Untersuchung der renommierten  Cochrane Collaberation aus dem Jahr 2019, die darauf hinweist, dass die sogenannte arthroskopische subacromiale Dekompression in den meisten Fällen keine Verbesserung gegenüber der nichtoperativen Therapie bringt.

https://www.oc-bayreuth.de/fileadmin/orthopaedische-chirurgie-daten/presse/Die_Zweitmeinung_bei_Schulterarthroskopie.pdf

Sie können sich aber auch das Patientenmerkblatt herunterladen unter: https://www.g-ba.de/downloads/17-98-4765/2019-10-28_G-BA_Patientenmerkblatt_Zweitmeinungsverfahren_bf.pdf

 

Falls Sie weitere Informationen benötigen:

Information der Kassenärztlichen Vereinigung:

www.kvb.de/praxis/qualitaet/qualitaetssicherung/zweitmeinungsverfahren/

Literatur:

Z Orthop Unfall  2020 Apr 21. doi: 10.1055/a-1114-6615. Online ahead of print.

Second Opinions Before Surgery Have the Potential to Reduce Costs - An Exploratory Analysis

Jan Weyerstraß  1 Barbara Prediger  2 Edmund Neugebauer  3 Dawid Pieper  4

Affiliations

Abstract:

Aim: In this study cost data of patient's first and second opinion of a German second opinion program of patients with orthopedic indications are raised and compared.

Methods: Anonymized patient data were used from a second opinion program gathered in the period from 2013 to 2015. Costs of the first and second opinion were raised using DRG, the EBM catalog, the remuneration agreement on physical therapy and the price of drugs. In order to increase transferability, initial therapy recommendation and second opinion were compared in a cost analysis to determine a theoretical savings potential.

Results: A total of 170 consecutive patients with orthopedic indication and first and second opinion were analyzed in this study. Only one out of three initial therapy recommendations was confirmed by the second opinion. In the second opinion, physiotherapy and pain therapy were often suggested for indications which received a surgery referral by the initial therapy recommendation. In scenario 1 (average resource use), the costs of the first therapy recommendation in median was 5020.96 € (IQR = 961.71 - 7342.66), the second opinion was 322.07 € (IQR = 146.39 - 1341.32). In median, the operation costs of the initial therapy recommendation were equal to 156.12 physiotherapeutic sessions and 26.02 N3 packs Ibuprofen 800.

Conclusion: Therapy costs for the initial therapy recommendation are clearly exceeding the therapy costs of the second opinion. This assumes a potential to reduce therapy costs with the use of a second opinion. This study lays the foundation to carry out further conclusive analyses concerning this matter.

-----------------------------------------------------------------------------------------------------------

 

Cochrane Database Syst Rev 2019 Jan 17;1(1):CD005619

Subacromial Decompression Surgery for Rotator Cuff Disease

Teemu V Karjalainen  1 Nitin B JainCristina M PageTuomas A LähdeojaRenea V JohnstonPaul SalamhLauri KavajaClare L ArdernArnav AgarwalPer O VandvikRachelle Buchbinder

 

Abstract

Background: Surgery for rotator cuff disease is usually used after non-operative interventions have failed, although our Cochrane Review, first published in 2007, found that there was uncertain clinical benefit following subacromial decompression surgery.

Objectives: To synthesise the available evidence of the benefits and harms of subacromial decompression surgery compared with placebo, no intervention or non-surgical interventions in people with rotator cuff disease (excluding full thickness rotator cuff tears).

Search methods: We searched CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICRTP registry from 2006 until 22 October 2018, unrestricted by language.

Selection criteria: We included randomised and quasi-randomised controlled trials (RCTs) of adults with rotator cuff disease (excluding full-thickness tears), that compared subacromial decompression surgery with placebo, no treatment, or any other non-surgical interventions. As it is least prone to bias, subacromial decompression compared with placebo was the primary comparison. Other comparisons were subacromial decompression versus exercises or non-operative treatment. Major outcomes were mean pain scores, shoulder function, quality of life, participant global assessment of success, adverse events and serious adverse events. The primary endpoint for this review was one year. For serious adverse events, we also included data from prospective cohort studies designed to record harms that evaluated subacromial decompression surgery or shoulder arthroscopy.

Data collection and analysis: We used standard methodologic procedures expected by Cochrane.

Main results: We included eight trials, with a total of 1062 randomised participants with rotator cuff disease, all with subacromial impingement. Two trials (506 participants) compared arthroscopic subacromial decompression with arthroscopy only (placebo surgery), with all groups receiving postoperative exercises. These trials included a third treatment group: no treatment (active monitoring) in one and exercises in the other. Six trials (556 participants) compared arthroscopic subacromial decompression followed by exercises with exercises alone. Two of these trials included a third arm: sham laser in one and open subacromial decompression in the other.Trial size varied from 42 to 313 participants. Participant mean age ranged between 42 and 65 years. Only two trials reported mean symptom duration (18 to 22 months in one trial and 30 to 31 months in the other), two did not report duration and four reported it categorically.Both placebo-controlled trials were at low risk of bias for the comparison of surgery versus placebo surgery. The other trials were at high risk of bias for several criteria, most notably at risk of performance or detection bias due to lack of participant and personnel blinding. We have restricted the reporting of results of benefits in the Abstract to the placebo-controlled trials.Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evidence, downgraded due to imprecision).At one year, mean pain (on a scale zero to 10, higher scores indicate more pain), was 2.9 points after placebo surgery and 0.26 better (0.84 better to 0.33 worse), after subacromial decompression (284 participants), an absolute difference of 3% (8% better to 3% worse), and relative difference of 4% (12% better to 5% worse). At one year, mean function (on a scale 0 to 100, higher score indicating better outcome), was 69 points after placebo surgery and 2.8 better (1.4 worse to 6.9 better), after surgery (274 participants), an absolute difference of 3% (7% better to 1% worse), and relative difference of 9% (22% better to 4% worse). Global success rate was 97/148 (or 655 per 1000), after placebo and 101/142 (or 708 per 1000) after surgery corresponding to RR 1.08 (95% CI 0.93 to 1.27). Health-related quality of life was 0.73 units (European Quality of Life EQ-5D, -0.59 to 1, higher score indicating better quality of life), after placebo and 0.03 units worse (0.011 units worse to 0.06 units better), after subacromial decompression (285 participants), an absolute difference of 1.3% (5% worse to 2.5% better), and relative difference of 4% (15% worse to 7% better).Adverse events including frozen shoulder or transient minor complications of surgery were reported in approximately 3% of participants across treatment groups in two randomised controlled trials, but due to low event rates we are uncertain if the risks differ between groups: 5/165 (37 per 1000) reported adverse events with subacromial decompression and 9/241 (34 per 1000) with placebo or non-operative treatment, RR 0.91 (95% CI 0.31 to 2.65) (moderate-certainty evidence, downgraded due to imprecision). The trials did not report serious adverse events.Based upon moderate-certainty evidence from two observational trials from the same prospective surgery registry, which also included other shoulder arthroscopic procedures (downgraded for indirectness), the incidence proportion of serious adverse events within 30 days following surgery was 0.5% (0.4% to 0.7%; data collected 2006 to 2011), or 0.6% (0.5 % to 0.7%; data collected 2011 to 2013). Serious adverse events such as deep infection, pulmonary embolism, nerve injury, and death have been observed in participants following shoulder surgery.

Authors' conclusions: The data in this review do not support the use of subacromial decompression in the treatment of rotator cuff disease manifest as painful shoulder impingement. High-certainty evidence shows that subacromial decompression does not provide clinically important benefits over placebo in pain, function or health-related quality of life. Including results from open-label trials (with high risk of bias) did not change the estimates considerably. Due to imprecision, we downgraded the certainty of the evidence to moderate for global assessment of treatment success; there was probably no clinically important benefit in this outcome either compared with placebo, exercises or non-operative treatment.Adverse event rates were low, 3% or less across treatment groups in the trials, which is consistent with adverse event rates reported in the two observational studies. Although precise estimates are unknown, the risk of serious adverse events is likely less than 1%.

-----------------------------------------------------------------------------------------------------------------

 

Arthroscopy 2020 Mar;36(3):913-922.

doi: 10.1016/j.arthro.2019.06.012. Epub 2019 Dec 25.

Indications for Arthroscopic Subacromial Decompression. A Level V Evidence Clinical Guideline

Erik Hohmann  1 Kevin Shea  2 Bastian Scheiderer  3 Peter Millett  4 Andreas Imhoff  5

Affiliations

Abstract

Since the introduction of acromioplasty by Neer in 1971 and arthroscopic subacromial decompression (SAD) by Ellman in 1987, the outcomes have been reported to be consistently good. Recently it was suggested that supervised physical therapy is comparable with SAD, which was contested by other studies claiming that SAD is clearly superior to nonoperative treatment. Before consideration for treatment, the diagnosis of impingement with an intact rotator cuff must be determined by clinical history, a detailed and structured clinical examination, and appropriate imaging. In favor of SAD are published long-term studies with a minimum of 10 years outlining significant functional and clinical improvement. The main factor for failure reported was workers compensation, calcific tendinopathy, and high-grade partial-thickness tears. Studies nonsupportive of SAD suffer from bias, crossover from the nonoperative group to the operative group following failure of conservative treatment, and loss of follow-up. Recently, lateral acromion resection has been suggested as a viable alternative, effectively reducing the critical shoulder angle. Following nonoperative treatment for at least 6 weeks, SAD is a viable and good surgical option for the treatment of shoulder impingement with an intact rotator cuff. Care should be taken to avoid resection of the acromioclavicular ligament. Five millimeters of lateral acromion resection is the recommended amount of resection. Patients with chronic calcific tendinitis, workers compensation, and partial-thickness tears should not be treated by SAD alone.

-----------------------------------------------------------------------------------------------------------------

Isr J Health Policy Res. 2017 Dec 8;6(1):67.

doi: 10.1186/s13584-017-0191-y.

Seeking a Second Medical Opinion: Composition, Reasons and Perceived Outcomes in Israel

Liora Shmueli  1 Nadav Davidovitch  2 Joseph S Pliskin  2   3 Ran D Balicer  4 Igal Hekselman  5 Geva Greenfield  6

Affiliations

Abstract

Background: Seeking a second-opinion (SO) is a common clinical practice that can optimize treatment and reduce unnecessary procedures and risks. We aim to characterize the composition of the population of SO seekers, their reasons for seeking a SO and choosing a specific physician, and their perceived outcomes following the SO.

Methods: A cross-sectional national telephone survey, using a representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, for the same medical concern. We describe the characteristics of respondents who obtained SOs, their reasons for doing so and their perceived outcomes: (1) Satisfaction with the SO; (2) Experiencing health improvement after receiving a SO; (3) A difference in the diagnosis or treatment suggested in the first opinions and the second opinions; (4) Preference of the SO over the first one.

Results: Most of the respondents who sought a SO (n = 344) were above 60 years old, secular, living with a partner, perceived their income to be above average and their health status to be not so good. For the patients who utilized SOs, orthopedic surgeons were sought out more than any other medical professional.Reasons for seeking a SO included doubts about diagnosis or treatment (38%), search for a sub-specialty expert (19%) and dissatisfaction with communication (19%). SO seekers most frequently chose a specific specialist based on a recommendation from a friend or a relative (33%). About half of the SO seekers also searched for information on the internet. Most of the respondents who sought a SO mentioned that they were satisfied with it (84%), felt health improvement (77%), mentioned that there was a difference between the diagnosis or treatment between the first opinion and the SO (56%) and preferred the SO over the first one (91%).

Conclusions: Clinical uncertainty or dissatisfaction with patient-physician communication were the main reasons for seeking a SO. Policy makers should be aware that many patients choose a physician for a SO based on recommendations made outside the medical system. We recommend creating mechanisms that help patients in the complicated process of seeking a SO, suggest specialists who are suitable for the specific medical problem of the patient, and provide tools to reconcile discrepant opinions.

-----------------------------------------------------------------------------------------------------------------

 

Isr J Health Policy Res . 2019 Jan 16;8(1):12.

doi: 10.1186/s13584-019-0289-5.

Obtaining a Second Opinion Is a Neglected Source of Health Care Inequalities

Jochanan Benbassat 1

Abstract

Observational studies have detected discrepancies between two expert interpreters of imaging and histopathological studies. Furthermore, in a substantial proportion of patients, an independent second opinion disagreed with the first one. Therefore, it is widely accepted that patients have a right to obtain a second opinion and, in case of divergent opinions, to deliberate and choose the option that they believe is most consistent with their individual circumstances. However, doctors are less likely to inform old and poorly educated patients about the possibility of seeking a second opinion, and this may contribute to healthcare inequalities. Hence the importance of (a) promoting doctors' self-awareness of a possible tendency to discriminate against old and poorly educated patients, and (b) creating programs within the healthcare system that would help patients in seeking a second opinion, suggest specialists for the specific problem of the patient, and provide tools to reconcile between discrepant opinions.

Keywords: Doctor-patient communication; Health policy; Health seeking behaviors; Second opinion.