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Regarding “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”

      We read with great interest the study by Hohmann et al.,
      • Hohmann E.
      • Glatt V.
      • Tetsworth K.
      Delphi Panel
      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.
      “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.” Undoubtedly, the management of patients with subacromial impingement (SI) is still controversial, expressed in this study by the fact that consensus could only be reached for 22% of the 71 Likert style items included.
      We wish to congratulate the authors for the enormous effort involved in carrying out this consensus, and we would like to raise a few observations about the interpretation of the study results and the role of subacromial decompression (SAD) in patients with SI.
      In 2009, 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.
      performed a randomized controlled trial (RCT) including 134 patients in which they compared a supervised exercise program (n = 66) with arthroscopic acromioplasty followed by a supervised exercise program (n = 68). No statistically significant difference was found neither in relation to the visual analog scale score nor in the secondary outcomes considered, which were pain at night, disability, shoulder disability questionnaire score, number of days experiencing pain, and number of patients without pain. In a similar study, Farfaras et al.
      • Farfaras S.
      • Sernert N.
      • Hallström E.
      • Kartus J.
      Comparison of open acromioplasty, arthroscopic acromioplasty and physiotherapy in patients with subacromial impingement syndrome: A prospective randomised study.
      randomized 55 patients with SI into open acromioplasty (n = 15), arthroscopic acromioplasty (n = 19), or physiotherapy (n = 21) treatment, and the authors also found no significant differences between the 3 groups in a period up to 3 years after the intervention.
      • Farfaras S.
      • Sernert N.
      • Hallström E.
      • Kartus J.
      Comparison of open acromioplasty, arthroscopic acromioplasty and physiotherapy in patients with subacromial impingement syndrome: A prospective randomised study.
      Some recent RCTs were performed, including a placebo surgery control group.
      • Beard D.J.
      • Rees J.L.
      • Cook J.A.
      • et al.
      CSAW Study Group
      Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): A multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomized surgical trial.
      ,
      • Paavola M.
      • Malmivaara A.
      • Taimela S.
      • et al.
      Finnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT) Investigators. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: Randomised, placebo surgery controlled clinical trial.
      In 2018, Beard et al.
      • Beard D.J.
      • Rees J.L.
      • Cook J.A.
      • et al.
      CSAW Study Group
      Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): A multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomized surgical trial.
      performed a multicenter, randomized, placebo-controlled, 3-group trial in 32 British hospitals. They included 313 patients who were randomly assigned to 1 of 3 treatment groups: (1) decompression surgery (n = 106), (2) diagnostic arthroscopy only (n = 103), and (3) no treatment (n = 104). No clinically significant difference was found by the authors in terms of pain or functional scores when comparing the surgical groups with the no-treatment group. Moreover, surgical decompression did not result in any additional positive effect when compared with arthroscopy only.
      In 2018, Paavola et al.
      • Paavola M.
      • Malmivaara A.
      • Taimela S.
      • et al.
      Finnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT) Investigators. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: Randomised, placebo surgery controlled clinical trial.
      performed another multicenter, 3-group, randomized, double-blind, sham-controlled trial in 3 Finnish public hospitals. They included 210 patients suffering from SI who were randomly classified into 1 of the following 3 treatment groups: (1) decompression surgery (n = 59), (2) diagnostic arthroscopy only (n = 63), and (3) exercise therapy (n = 71). They found that SAD was not any better than diagnostic arthroscopy at 24 months. Likewise, there appear to be no long-term benefits associated with SAD in patients with SI. In 2017, Ketola et al.
      • Ketola S.
      • Lehtinen J.T.
      • Arnala I.
      Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy: A final review of a randomised controlled trial at a minimum follow-up of ten years.
      published the long-term outcomes from their previously published RCT in 2009.
      • 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.
      From the initial 134 patients, 90 (64%) were evaluated for a mean period of 12 years after being randomized. In line with the results obtained in the short-term assessment, the final long-term follow-up revealed no statistically significant differences in either pain or any functional outcome measures. Therefore, it is important to emphasize that multiple, high-quality randomized controlled trials showed that SAD failed to provide improvements in pain, function, or quality of life compared with a placebo surgical procedure or other conservative treatments for patients with SI. It is time to ask ourselves why and for what we shoulder surgeons keep doing SAD when the benefits of this procedure still need to be proven.

      Supplementary Data

      References

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        • Glatt V.
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        • Delphi Panel
        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.
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