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Author Reply: Arthroscopic Subacromial Decompression. What Are the Indications? A Level V Evidence Clinical Guideline

      We thank the authors for their interest in our level V evidence clinical guideline discussing the indications for arthroscopic subacromial decompression (SAD) in patients with shoulder impingement without rotator cuff tears.
      • Hohmann E.
      • Shea K.
      • Schneiderer B.
      • Millett P.
      • Imhoff A.
      Indications for subacromial decompression. A level V evidence clinical guideline.
      In their letter to the editor, van den Bekerom and Poolman
      • van den Bekerom M.P.J.
      • Poolman R.W.
      No indications for subacromial decompression in cuff tendinopathy. A level 1 evidence clinical guideline.
      argue strongly against SAD and referenced several published trials in support.
      • Vandvik P.O.
      • Lähdeoja T.
      • Ardern C.
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: A clinical practice guideline.
      • Karjalainen T.V.
      • Jain N.B.
      • Page C.M.
      • et al.
      Subacromial decompression surgery for rotator cuff disease.
      • Jones T.
      • Carr A.J.
      • Beard D.
      • et al.
      Longitudinal study of use and cost of subacromial decompression surgery: The need for effective evaluation of surgical procedures to prevent overtreatment and wasted resources.
      • Ketola S.
      • Lehtinen J.
      • Rousi T.
      • Nissinen M.
      • Huhtala H.
      • Arnala I.
      Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment?.
      We agree that there is no current and strong evidence to either support SAD or nonoperative treatment. In the introduction, we have clearly stated that credible, reliable, reproducible, and valid evidence is required. Therefore, surgeons have to rely on clinical judgment and careful patient selection. van den Bekerom and Poolman
      • van den Bekerom M.P.J.
      • Poolman R.W.
      No indications for subacromial decompression in cuff tendinopathy. A level 1 evidence clinical guideline.
      have based their opinion on a recently published meta-analysis
      • Karjalainen T.V.
      • Jain N.B.
      • Page C.M.
      • et al.
      Subacromial decompression surgery for rotator cuff disease.
      and a randomized trial investigating failures in both surgical and nonoperative treatment.
      • Ketola S.
      • Lehtinen J.
      • Rousi T.
      • Nissinen M.
      • Huhtala H.
      • Arnala I.
      Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment?.
      The meta-analysis of Karjalainen et al.
      • Karjalainen T.V.
      • Jain N.B.
      • Page C.M.
      • et al.
      Subacromial decompression surgery for rotator cuff disease.
      included 8 studies and concluded that SAD does not provide clinically important benefits over placebo; however, due to the imprecision of results, the certainty of evidence was downgraded to moderate. Of the 8 included studies, 6 had a high risk of bias. One included study used an intention-to-treat protocol (per protocol) and of 25% of the patients in the placebo group had surgery within 12 months.
      • Beard D.J.
      • Rees J.L.
      • Cook J.A.
      • et al.
      Arthroscopic subacromial decompression for subacromial shoulder pain: A multicentre, pragmatic, parallel group, placebo-controlled, three group, randomised surgical trial.
      Although the risk of bias was considered low, the authors had to contact the senior author, who confirmed verbally that postoperative personnel were unaware of treatment allocation. The study by Beard et al.
      • Beard D.J.
      • Rees J.L.
      • Cook J.A.
      • et al.
      Arthroscopic subacromial decompression for subacromial shoulder pain: A multicentre, pragmatic, parallel group, placebo-controlled, three group, randomised surgical trial.
      has been criticized by multiple German-speaking associations

      Gemeinsame Stellungnahme der AGA, DGOOC, DVSE; BVOU, BDC, BVASK, GOTS. Zum Can Shoulder Arthroscopy Work?-Trial (ISRCTN33864128), published in: Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, et al. (2017) Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomized surgical trial. Lancet 2017 Nov 20. http://www.aga-online.ch/komitees/kommunikationmitglieder/gemeinsame-stellungnahme-zum-csaw-studien-artikel-im-lancet/.

      because of its multiple biases, as we have highlighted in our guideline.
      • Hohmann E.
      • Shea K.
      • Schneiderer B.
      • Millett P.
      • Imhoff A.
      Indications for subacromial decompression. A level V evidence clinical guideline.
      Similarly, the second study included in the meta-analysis that was assessed as low risk of bias used an intention-to-treat protocol.
      • Paavola M.
      • Malmivaara A.
      • Taimela S.
      • et al.
      Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: Randomised, placebo controlled clinical trial.
      Twelve percent of patients in the placebo group and 21% of patients in the exercise group eventually crossed over and had surgery.
      • Paavola M.
      • Malmivaara A.
      • Taimela S.
      • et al.
      Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: Randomised, placebo controlled clinical trial.
      Crossover compromises interpretation of outcomes if the percentage of patients crossing over is one way.
      • Lubowitz J.H.
      • D’Agostino Jr., R.B.
      • Provencher M.T.
      • Rossi M.J.
      • Brand J.C.
      Can we trust meniscus studies? One-way cross-over confound intent-to-treat statistical methods.
      In addition, patients who cross over usually have more symptoms and comparing patients with more symptoms with patients who have good results with nonoperative treatment results in systematic error and bias.
      • Lubowitz J.H.
      • D’Agostino Jr., R.B.
      • Provencher M.T.
      • Rossi M.J.
      • Brand J.C.
      Can we trust meniscus studies? One-way cross-over confound intent-to-treat statistical methods.
      The second study referenced in support against subacromial decompression was published by Ketola et al.
      • Ketola S.
      • Lehtinen J.
      • Arnala I.
      • et al.
      Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome? A two-year randomised controlled trial.
      This study suffers from significant bias, as there was missing data at 3, 6, and 12 months in both the surgery and exercise group, 13% in the surgery group also received labral repair, both groups received corticosteroid injections over the 2-year follow-up period, 18% in the surgery group did not receive the planned surgery, and 20% of the exercise group eventually had decompression surgery.
      • Ketola S.
      • Lehtinen J.
      • Arnala I.
      • et al.
      Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome? A two-year randomised controlled trial.
      High risk of bias, low study quality, and heterogeneity does not allow any meaningful conclusions to be drawn, and the conclusions of systematic reviews and meta-analyses including these studies must be viewed with extreme caution.
      • Hohmann E.
      • Glatt V.
      • Tetsworth K.
      • Cote M.
      Arthroscopic partial meniscectomy versus physical therapy for degenerative meniscus lesions: How robust is the current evidence? A critical systematic review and qualitative synthesis.
      In their final statement van den Bekerom and Poolman
      • van den Bekerom M.P.J.
      • Poolman R.W.
      No indications for subacromial decompression in cuff tendinopathy. A level 1 evidence clinical guideline.
      commented that there are strong recommendations against surgery based on the current clinical practice guideline for adults with shoulder pain recently published in the British Medical Journal.
      • Vandvik P.O.
      • Lähdeoja T.
      • Ardern C.
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: A clinical practice guideline.
      We have discussed the value of these recommendations very critically in our Level V clinical guideline already.
      • Hohmann E.
      • Shea K.
      • Schneiderer B.
      • Millett P.
      • Imhoff A.
      Indications for subacromial decompression. A level V evidence clinical guideline.
      The recommendations by Vandvik et al.
      • Vandvik P.O.
      • Lähdeoja T.
      • Ardern C.
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: A clinical practice guideline.
      were based on Beard et al.,
      • Beard D.J.
      • Rees J.L.
      • Cook J.A.
      • et al.
      Arthroscopic subacromial decompression for subacromial shoulder pain: A multicentre, pragmatic, parallel group, placebo-controlled, three group, randomised surgical trial.
      Paavola et al.,
      • Paavola M.
      • Malmivaara A.
      • Taimela S.
      • et al.
      Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: Randomised, placebo controlled clinical trial.
      and Lähdeoja et al.
      • Lähdeoja T.
      • Karjalainen T.
      • Jokihaara J.
      • et al.
      Subacromial decompression surgery versus conservative management in patients with shoulder pain: A systematic review with meta-analysis.
      We have outlined the concerns for the studies by Beard and Paavola already. Lähdeoja et al.
      • Lähdeoja T.
      • Karjalainen T.
      • Jokihaara J.
      • et al.
      Subacromial decompression surgery versus conservative management in patients with shoulder pain: A systematic review with meta-analysis.
      performed a meta-analysis and compared SAD with exercise and diagnostic arthroscopy. Interestingly, their study demonstrated a significant advantage of SAD over exercise and diagnostic arthroscopy at all time intervals.
      • Lähdeoja T.
      • Karjalainen T.
      • Jokihaara J.
      • et al.
      Subacromial decompression surgery versus conservative management in patients with shoulder pain: A systematic review with meta-analysis.
      In addition, the authors have not set strict inclusion criteria but accepted studies with homemade criteria.
      • Lähdeoja T.
      • Karjalainen T.
      • Jokihaara J.
      • et al.
      Subacromial decompression surgery versus conservative management in patients with shoulder pain: A systematic review with meta-analysis.
      We will leave it to the readers of Arthroscopy to judge the value of the recent BMJ guideline.
      • Vandvik P.O.
      • Lähdeoja T.
      • Ardern C.
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: A clinical practice guideline.
      Critical shoulder angle (CSA) and lateral acromion resection (LAR) is a new concept. Katthagen et al. and Marchetti et al. have shown that an arthroscopic anterolateral acromioplasty and a 5-mm lateral acromion resection each reduced the CSA significantly and did not damage the deltoid origin.
      • Marchetti D.C.
      • Katthagen J.C.
      • Mikula J.D.
      • et al.
      Impact of arthroscopic lateral acromioplasty on the mechanical and structural integrity of the lateral deltoid origin: A cadaveric study.
      • Katthagen J.C.
      • Marchetti D.C.
      • Tahal D.
      • Turnbull T.L.
      • Millett P.J.
      The effects of arthroscopic lateral acromioplasty on the critical shoulder angle and the anterolateral deltoid origin: an anatomic cadaveric study.
      • Katthagen J.C.
      • Millett P.J.
      Editorial Commentary: Lateral acromioplasty is clinically safe and has the potential to reduce rotator cuff re-tears.
      It appears that there is a relationship between a greater CSA and full-thickness rotator cuff tears supporting the concept of LAR.
      • Docter S.
      • Khan M.
      • Ektiari S.
      • et al.
      The relationship between the critical shoulder angle and the incidence of chronic, full-thickness rotator cuff tears and outcomes after rotator cuff repair: A systematic review.
      In addition, re-tear rates are greater in patients with a larger CSAs.
      • Sheean A.J.
      • Sa D.
      • Woolnough T.
      • Cognetti D.J.
      • Kay J.
      • Burkhart S.S.
      Does an increased critical shoulder angle affect re-tear rates and clinical outcomes following primary rotator cuff repair? A systematic review.
      The mean CSA in patients who did not have RC re-tears ranged from 34.3° to 37°, and the mean CSA in those patients who had rotator cuff re-tears ranged from 37° to 40°.
      • Sheean A.J.
      • Sa D.
      • Woolnough T.
      • Cognetti D.J.
      • Kay J.
      • Burkhart S.S.
      Does an increased critical shoulder angle affect re-tear rates and clinical outcomes following primary rotator cuff repair? A systematic review.
      Gerber et al.
      • Gerber C.
      • Catanzaro S.
      • Betz M.
      • Ernstbrunner L.
      Arthroscopic correction of the critical shoulder angle through lateral acromioplasty: A safe adjunct to rotator cuff repair.
      demonstrated that arthroscopic lateral acromioplasty reduces CSA without compromising the deltoid origin or function in patients undergoing arthroscopic rotator cuff repairs. The authors have also reported greater re-tear rates and inferior abduction strength with an abnormally large CSA.
      • Gerber C.
      • Catanzaro S.
      • Betz M.
      • Ernstbrunner L.
      Arthroscopic correction of the critical shoulder angle through lateral acromioplasty: A safe adjunct to rotator cuff repair.
      As such, the concept of LAR seems to be supported by the current published literature.
      As we have outlined in our clinical guideline, SAD is a safe procedure with proven long-term outcomes,
      • Brox J.I.
      • Gjengedal E.
      • Uppheim G.
      • et al.
      Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): A prospective, randomized, controlled study in 125 patients with a 2 ½-year follow-up.
      • Norlin R.
      • Adolfsson L.
      Small full-thickness tears do well ten to thirteen years after arthroscopic subacromial decompression.
      • Jaeger M.
      • Berndt T.
      • Rühmann O.
      • Lerch S.
      Patients with impingement syndrome with and without rotator cuff repair do well 20 years after arthroscopic subacromial decompression.
      • Farfaras S.
      • Sernert N.
      • Rostgard Christensen L.
      • Hallström E.K.
      • Kartus J.T.
      Subacromial decompression yields a better clinical outcome than therapy alone: A prospective randomized study of patients with a minimum of 10-year follow-up.
      and we suggest to consider SAD if the following 5 criteria are met: pain including night pain for at least 6 months; persistently positive Hawkins test; persistence of symptoms despite physical therapy for at least 6 weeks including a short course of anti-inflammatory medication; radiologic evidence of mechanical impingent; and consideration of a corticosteroid injection as initial treatment and a diagnostic tool. When performing subacromial decompression the coracoacromial ligament should be kept intact, a high degree partial-thickness tear should be repaired and a CSA above 35° can be considered as an indication for a lateral acromioplasty.

      Supplementary Data

      References

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