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Original Article| Volume 38, ISSUE 4, P1051-1065, April 2022

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Subacromial Decompression in Patients With Shoulder Impingement With an Intact Rotator Cuff: An Expert Consensus Statement Using the Modified Delphi Technique Comparing North American to European Shoulder Surgeons

  • Erik Hohmann
    Correspondence
    Address correspondence to Erik Hohmann, Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates.
    Affiliations
    Department of Orthopaedic Surgery and Sportsmedicine, Valiant Clinic/Houston Methodist, Dubai, United Arab Emirates
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  • Vaida Glatt
    Affiliations
    University of Texas Health Science Centre, San Antonio, Texas, U.S.A.
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  • Kevin Tetsworth
    Affiliations
    Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia

    Orthopaedic Research Centre of Australia, Sydney, Australia
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  • and the
    Author Footnotes
    Delphi European Panel: Eduard Alentorn-Geli, Instituto Cugat, Hospital Quironslaud, Barcelona, Spain; Klaus Bak, Adeas Hospitals Skodsborg & Parken, Copenhagen, Denmark; Knut Beitzel, Atos Orthoparc Clinic, Cologne, Germany; Berte Bøe, Division of Orthopaedic Surgery, Oslo University Hospital, Norway; Emilio Calvo, Department of Orthopaedic Surgery and Traumatology, Universidad Autonoma, Madrid, Spain; Giovanni Di Giacomo, Concordia Hospital, Rome, Italy; Luc Favard, Tours University Hospital, University of Tours, Tours, France; Francesco Franceschi, Campus Biomedico, University of Rome, Rome, Italy; Lennard Funk, Upper Limb Unit, Wrightington Hospital, Wrightington, United Kingdom; Michael Glanzmann, Schulthess Klinik, Zürich, Switzerland; Andreas Imhoff, Department of Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany; Alexandre Lädermann, Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland; Ofer Levy, Reading Shoulder Unit, Berkshire Independent Hospital, Reading, Berkshire, United Kingdom; The Israeli Shoulder Institute, Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel; Tom Ludvigsen, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Giuseppe Milano, Unit of Orthopaedics and Traumatology, University of Brescia, Brescia, Italy; Philipp Moroder, Department of Shoulder and Elbow Surgery, Centrum for Muskuloskeletale Chirurgie, Charite Universitätsmedizin Berlin, Berlin, Germany; Claudio Rosso, ArthroMedics, Basel, Switzerland; Sebastian Siebenlist, Department of Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany. Delphi North America: Jeffrey Abrams, Princeton Orthopeadic Associates, Princeton, New Jersey, U.S.A.; Robert Arciero, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; George Athwal, Roth/McFarlane Hand & Upper limb Centre, St. Joseph’s Health Care, London, Ontario, Canada; Robert Burks, University of Utah, Salt Lake City, Utah, U.S.A.; Robert Gillespie, Department of Orthopaedics, Case Western Reserve University, University Hospital Cleveland Medical Center, Cleveland, Ohio, U.S.A.; Ben Kibler, Lexington Orthopaedic Clinic, Sports Medicine Center, Lexington, Kentucky, U.S.A.; William Levine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, U.S.A.; Augustus Mazzocca, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; Peter Millett, Steadman Clinic, Vail, Colorado, U.S.A.; Richard Ryu, The Ryu Hurvitz Orthopaedic Clinic, Santa Barbara, California, U.S.A.; Marc Safran, Department of Orthopaedic Surgery, Stanford University, Stanford, California, U.S.A.; Joaquin Sanchez-Sotelo, Department of Orthopaedic Surgery, The Mayo Clinic, Rochester, Minnesota, U.S.A.; Felix “Buddy” Savoie, Department of Orthopaedic Surgery, Tulane University, New Orleans, Louisiana, U.S.A.; Paul Sethi, The ONS Sports and Shoulder Service, Greenwich, Connecticut, U.S.A.; Kevin Shea, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; Nikhil Verma, Midwest Orthopaedics at Rush University, Chicago, Illinois, U.S.A.; Jon J. P. Warner, Massachusetts General Hospital, The Boston Shoulder Institute, Boston, Massachusetts, U.S.A.; Stephen Weber, Sutter Medical Center, Silver Springs, Maryland, U.S.A.; Brian Wolf, Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa, U.S.A.
    Delphi Panel
    Footnotes
    Delphi European Panel: Eduard Alentorn-Geli, Instituto Cugat, Hospital Quironslaud, Barcelona, Spain; Klaus Bak, Adeas Hospitals Skodsborg & Parken, Copenhagen, Denmark; Knut Beitzel, Atos Orthoparc Clinic, Cologne, Germany; Berte Bøe, Division of Orthopaedic Surgery, Oslo University Hospital, Norway; Emilio Calvo, Department of Orthopaedic Surgery and Traumatology, Universidad Autonoma, Madrid, Spain; Giovanni Di Giacomo, Concordia Hospital, Rome, Italy; Luc Favard, Tours University Hospital, University of Tours, Tours, France; Francesco Franceschi, Campus Biomedico, University of Rome, Rome, Italy; Lennard Funk, Upper Limb Unit, Wrightington Hospital, Wrightington, United Kingdom; Michael Glanzmann, Schulthess Klinik, Zürich, Switzerland; Andreas Imhoff, Department of Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany; Alexandre Lädermann, Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland; Ofer Levy, Reading Shoulder Unit, Berkshire Independent Hospital, Reading, Berkshire, United Kingdom; The Israeli Shoulder Institute, Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel; Tom Ludvigsen, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Giuseppe Milano, Unit of Orthopaedics and Traumatology, University of Brescia, Brescia, Italy; Philipp Moroder, Department of Shoulder and Elbow Surgery, Centrum for Muskuloskeletale Chirurgie, Charite Universitätsmedizin Berlin, Berlin, Germany; Claudio Rosso, ArthroMedics, Basel, Switzerland; Sebastian Siebenlist, Department of Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany. Delphi North America: Jeffrey Abrams, Princeton Orthopeadic Associates, Princeton, New Jersey, U.S.A.; Robert Arciero, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; George Athwal, Roth/McFarlane Hand & Upper limb Centre, St. Joseph’s Health Care, London, Ontario, Canada; Robert Burks, University of Utah, Salt Lake City, Utah, U.S.A.; Robert Gillespie, Department of Orthopaedics, Case Western Reserve University, University Hospital Cleveland Medical Center, Cleveland, Ohio, U.S.A.; Ben Kibler, Lexington Orthopaedic Clinic, Sports Medicine Center, Lexington, Kentucky, U.S.A.; William Levine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, U.S.A.; Augustus Mazzocca, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; Peter Millett, Steadman Clinic, Vail, Colorado, U.S.A.; Richard Ryu, The Ryu Hurvitz Orthopaedic Clinic, Santa Barbara, California, U.S.A.; Marc Safran, Department of Orthopaedic Surgery, Stanford University, Stanford, California, U.S.A.; Joaquin Sanchez-Sotelo, Department of Orthopaedic Surgery, The Mayo Clinic, Rochester, Minnesota, U.S.A.; Felix “Buddy” Savoie, Department of Orthopaedic Surgery, Tulane University, New Orleans, Louisiana, U.S.A.; Paul Sethi, The ONS Sports and Shoulder Service, Greenwich, Connecticut, U.S.A.; Kevin Shea, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; Nikhil Verma, Midwest Orthopaedics at Rush University, Chicago, Illinois, U.S.A.; Jon J. P. Warner, Massachusetts General Hospital, The Boston Shoulder Institute, Boston, Massachusetts, U.S.A.; Stephen Weber, Sutter Medical Center, Silver Springs, Maryland, U.S.A.; Brian Wolf, Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa, U.S.A.
    Authors List
  • Author Footnotes
    Delphi European Panel: Eduard Alentorn-Geli, Instituto Cugat, Hospital Quironslaud, Barcelona, Spain; Klaus Bak, Adeas Hospitals Skodsborg & Parken, Copenhagen, Denmark; Knut Beitzel, Atos Orthoparc Clinic, Cologne, Germany; Berte Bøe, Division of Orthopaedic Surgery, Oslo University Hospital, Norway; Emilio Calvo, Department of Orthopaedic Surgery and Traumatology, Universidad Autonoma, Madrid, Spain; Giovanni Di Giacomo, Concordia Hospital, Rome, Italy; Luc Favard, Tours University Hospital, University of Tours, Tours, France; Francesco Franceschi, Campus Biomedico, University of Rome, Rome, Italy; Lennard Funk, Upper Limb Unit, Wrightington Hospital, Wrightington, United Kingdom; Michael Glanzmann, Schulthess Klinik, Zürich, Switzerland; Andreas Imhoff, Department of Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany; Alexandre Lädermann, Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland; Ofer Levy, Reading Shoulder Unit, Berkshire Independent Hospital, Reading, Berkshire, United Kingdom; The Israeli Shoulder Institute, Faculty of Health Sciences, Ben-Gurion University, Beer Sheva, Israel; Tom Ludvigsen, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway; Giuseppe Milano, Unit of Orthopaedics and Traumatology, University of Brescia, Brescia, Italy; Philipp Moroder, Department of Shoulder and Elbow Surgery, Centrum for Muskuloskeletale Chirurgie, Charite Universitätsmedizin Berlin, Berlin, Germany; Claudio Rosso, ArthroMedics, Basel, Switzerland; Sebastian Siebenlist, Department of Orthopaedic Sports Medicine, Technical University Munich, Munich, Germany. Delphi North America: Jeffrey Abrams, Princeton Orthopeadic Associates, Princeton, New Jersey, U.S.A.; Robert Arciero, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; George Athwal, Roth/McFarlane Hand & Upper limb Centre, St. Joseph’s Health Care, London, Ontario, Canada; Robert Burks, University of Utah, Salt Lake City, Utah, U.S.A.; Robert Gillespie, Department of Orthopaedics, Case Western Reserve University, University Hospital Cleveland Medical Center, Cleveland, Ohio, U.S.A.; Ben Kibler, Lexington Orthopaedic Clinic, Sports Medicine Center, Lexington, Kentucky, U.S.A.; William Levine, Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York, U.S.A.; Augustus Mazzocca, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; Peter Millett, Steadman Clinic, Vail, Colorado, U.S.A.; Richard Ryu, The Ryu Hurvitz Orthopaedic Clinic, Santa Barbara, California, U.S.A.; Marc Safran, Department of Orthopaedic Surgery, Stanford University, Stanford, California, U.S.A.; Joaquin Sanchez-Sotelo, Department of Orthopaedic Surgery, The Mayo Clinic, Rochester, Minnesota, U.S.A.; Felix “Buddy” Savoie, Department of Orthopaedic Surgery, Tulane University, New Orleans, Louisiana, U.S.A.; Paul Sethi, The ONS Sports and Shoulder Service, Greenwich, Connecticut, U.S.A.; Kevin Shea, Department of Orthopaedic Surgery, UCONN Health, Farmington, Connecticut, U.S.A.; Nikhil Verma, Midwest Orthopaedics at Rush University, Chicago, Illinois, U.S.A.; Jon J. P. Warner, Massachusetts General Hospital, The Boston Shoulder Institute, Boston, Massachusetts, U.S.A.; Stephen Weber, Sutter Medical Center, Silver Springs, Maryland, U.S.A.; Brian Wolf, Department of Orthopaedic Surgery, University of Iowa, Iowa City, Iowa, U.S.A.
Published:October 13, 2021DOI:https://doi.org/10.1016/j.arthro.2021.09.031

      Purpose

      To perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American with European shoulder surgeon preferences.

      Methods

      Nineteen surgeons from North America (North American panel [NAP]) and 18 surgeons from Europe (European panel [EP]) agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤60% for an item, the results were carried forward into round 4. For round 4, the panel members outside consensus (>60%, <80%) were contacted and asked to review their response. The level of agreement and consensus was defined as 80%.

      Results

      There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the workup; magnetic resonance imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of nonoperative treatment for a minimum of 6 months. The NAP was likely to routinely prescribe nonsteroidal anti-inflammatory drugs (NAP 89%; EP 35%) and consider steroids for impingement (NAP 89%; EP 65%).

      Conclusions

      Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of no-operative treatment for a minimum of 6 months. The panel also agreed that subacromial decompression is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to nonsurgical measures.

      Level of Evidence

      Level V, expert opinion.
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