Sunday, January 5, 2014

No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome

No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome Five-year results of a randomised controlled trial

As our regular readers know, we've been trying to gently lay to rest the historical concept of acromioplasty for 'impingement syndrome'. 

In that vein, this article, perhaps hidden from the view of many, is of interest. The authors reported the five-year results of a randomised controlled trial examining the effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. 

Inclusion criteria
Clinical symptoms of shoulder impingement syndrome
A positive Neer’s test
Symptom duration of at least three months
Attempts to treat with: rest, NSAIDs, subacromial corticosteroid injections and regular physiotherapy
Age between 18 and 60 years
No previous operations on shoulder region
Willingness and capacity to comply with the treatment protocol and follow-up visits

Exclusion criteria
Signs of glenohumeral instability
A penetrating rupture of the rotator cuff
Cervical radicular syndrome
Adhesive capsulitis
Neuropathy of the shoulder region

They included total of 140 patients were randomly divided into two groups: 1) supervised exercise program (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise program (n = 70, combined treatment group).

At the five-year assessment a total of 109 patients were examined (52 in the exercise group and 57 in the combined treatment group). 

There was no difference in outcome with respect to pain reduction:
The VAS pain score for the exercise group decreased from 6.5 (1 to 10) to 2.2 (0 to 8); p < 0.001) 
The VAS pain score for the acromioplasty group decreased from 6.4 (2 to 10) to 1.9 (0 to 8); p < 0.001). 

The same trend was seen in the secondary outcome measures (disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days). An intention-to-treat analysis showed statistically significant improvements in both groups at five years compared with baseline. Further, improvement continued between the two- and five-year timepoints. No statistically significant differences were found in the patient-centred parameters between the two treatment groups.

In the absence of differences in the patient-centred primary and secondary parameters between the two treatment groups, the authors concluded  that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome.

Other recent articles have pointed to the value of non-acromioplasty treatment for the treatment of rotator cuff syndromes, such as
(1) The role of acromion morphology in chronic subacromial impingement syndrome which concluded that arthroscopic subacromial decompression without simultaneous acromioplasty thus appears as an appropriate treatment.
(2) Arthroscopic subacromial decompression: acromioplasty versus bursectomy alone--does it really matter? A systematic review. which concluded that bursectomy alone provides similar outcomes to bursectomy with acromioplasty.
(3) Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomized controlled trial, finding that while more expensive, arthroscopic acromioplasty provided no clinically important effects over a structured and supervised exercise program alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome.
(4) Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomized study, which concluded that bursectomy and acromioplasty gave the same clinical results. 

Although the rate of publication of articles on acromioplasty are declining, articles on the 'impingement syndrome' are appearing at an ever increasing rate as this morning's assessment via PubMed (stimulated by last night's dinner conversation).


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