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No Indications for Subacromial Decompression in Rotator Cuff Tendinopathy: A Level I Evidence Clinical Guideline

      We read with interest the article “Indications for Arthroscopic Subacromial Decompression. Level V Evidence Clinical Guideline” by Hohman et al.
      • Hohmann E.
      • Shea K.
      • Scheiderer B.
      • Millett P.
      • Imhoff A.
      Indications for arthroscopic subacromial decompression. A level V evidence clinical guideline.
      The authors well described the history, physical examination, relevant radiology, and treatment of patients with rotator cuff pain. I think it is important for the readers of Arthroscopy to interpret the conclusions and recommendations formulated in this guideline in the light of some comments.
      The authors discuss the supporting evidence in favor of subacromial decompression (SAD). Unfortunately, this there is no such evidence. Based on a recent meta-analysis assessing the benefits and harms of SAD surgery compared with placebo, no intervention, or nonsurgical interventions, there is no support for the use of surgery in people with rotator cuff tendinopathy.
      • Karjalainen T.V.
      • Jain N.B.
      • Page C.M.
      • et al.
      Subacromial decompression surgery for rotator cuff disease.
      We agree with the authors that the concept of the critical shoulder angle (CSA) in rotator cuff pain and especially in tears is promising.
      • Smith G.C.S.
      • Liu V.
      • Lam P.H.
      The critical shoulder angle shows a reciprocal change in magnitude when evaluating symptomatic full-thickness rotator cuff tears versus primary glenohumeral osteoarthritis as compared with control subjects: A systematic review and meta-analysis.
      Although the first results of changing the CSA have been published, we still do not know if changing the CSA is really beneficial in treating rotator cuff pain in the long term.
      • Katthagen J.C.
      • Millett P.J.
      Editorial Commentary: Lateral acromioplasty is clinically safe and has the potential to reduce the risk for rotator cuff re-tears.
      ,
      • Degen R.M.
      Editorial Commentary: Critical shoulder angle: Perhaps not so "critical" for clinical outcomes following rotator cuff repair.
      From recent placebo-controlled randomized trials and the BMJ Guideline, we can conclude that even sham surgery in patients with rotator cuff pain will lead to improvement in shoulder function.
      • Vandvik P.O.
      • Lähdeoja T.
      • Ardern C.
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: A clinical practice guideline.
      Jones et al.
      • 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.
      recently concluded that high-quality randomized trials are needed before widespread adoption of promising operative procedures so as to avoid overtreatment and wasted resources. The question remains: is performing a lateral acromion resection ethical when doing it outside an experimental setting and comparing it with placebo/sham surgery?
      The authors conclude that if symptoms persist despite physical therapy for at least 6 weeks, including a short course of anti-inflammatory medication, an SAD can be considered. However, Ketola et al.
      • 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?.
      concluded that patients who do not recover after nonoperative treatment should not be operated on either, which is an important finding for clinical practice. We are not aware of evidence that patients with a long-lasting and failed nonoperative treatment will improve from surgery. If patients are treated surgically after a short nonoperative treatment, time may also heal these patients, but when there is no comparison with a persisting nonoperative treatment group we are not able to draw conclusions.
      All studies and subsequent guidelines are subject to potential biases, and of course these have to be discussed. However, the burden of proof lies with those who claim that SAD is effective for treating long-lasting shoulder pain. This proof must be built on high-quality experiments. Based on meta-analyses of the highest-level studies available today, there is no evidence that surgery results in superior outcome compared with placebo surgery or nonsurgical treatment in patients with (intact) rotator cuff pain in the absence of acromion spurs, osteophytes, and calcifications. Therefore, currently there is strong recommendation against surgery in these patients.
      • Vandvik P.O.
      • Lähdeoja T.
      • Ardern C.
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: A clinical practice guideline.

      Supplementary Data

      References

        • Hohmann E.
        • Shea K.
        • Scheiderer B.
        • Millett P.
        • Imhoff A.
        Indications for arthroscopic subacromial decompression. A level V evidence clinical guideline.
        Arthroscopy. 2020; 36: 913-922
        • Karjalainen T.V.
        • Jain N.B.
        • Page C.M.
        • et al.
        Subacromial decompression surgery for rotator cuff disease.
        Cochrane Database Syst Rev. 2019; 1: CD005619
        • Smith G.C.S.
        • Liu V.
        • Lam P.H.
        The critical shoulder angle shows a reciprocal change in magnitude when evaluating symptomatic full-thickness rotator cuff tears versus primary glenohumeral osteoarthritis as compared with control subjects: A systematic review and meta-analysis.
        Arthroscopy. 2020; 36: 566-575
        • Katthagen J.C.
        • Millett P.J.
        Editorial Commentary: Lateral acromioplasty is clinically safe and has the potential to reduce the risk for rotator cuff re-tears.
        Arthroscopy. 2018; 34: 781-783
        • Degen R.M.
        Editorial Commentary: Critical shoulder angle: Perhaps not so "critical" for clinical outcomes following rotator cuff repair.
        Arthroscopy. 2018; 34: 2755-2756
        • Vandvik P.O.
        • Lähdeoja T.
        • Ardern C.
        • et al.
        Subacromial decompression surgery for adults with shoulder pain: A clinical practice guideline.
        BMJ. 2019; 364: 1294
        • 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.
        BMJ Open. 2019; 9e030229
        • 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?.
        Acta Orthop. 2015; 86: 641-646

      Linked Article

      • Author Reply: Arthroscopic Subacromial Decompression. What Are the Indications? A Level V Evidence Clinical Guideline
        ArthroscopyVol. 36Issue 6
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          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.1 In their letter to the editor, van den Bekerom and Poolman2 argue strongly against SAD and referenced several published trials in support.3-6 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.
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