Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?

Abstract

We report a randomised controlled trial to examine the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n = 70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available. An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p = 0.65). The combined treatment was considerably more costly. Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme 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, with operative treatment offered judiciously until its true merit is proven.

Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment?

“…Our study indicates that using self-reported pain (by VAS) or secondary outcome measures at 2 or 5 years for analysis, the effects of combined treatment did not differ significantly from the effects of treatment with supervised exercise alone. In this study we did not compare the overall effects of these 2 modes of treatment, but specifically analyzed the eventual additional value provided by the operation over and beyond the effect obtained using a structured and supervised exercise program alone (Ketola et al 2009 and 2013).…”

“…None of the patients had had previous shoulder surgery. The inclusion and exclusion criteria and the precise study protocol are described in the report of the 2-year results (Ketola et al 2009). …”

“…In most studies, the inclusion criterion has simply been failure of nonoperative treatment (Brox et al 1999, Henkus et al 2009). We have already done a cost-effectiveness study that suggested that arthroscopic acromioplasty followed by a structural exercise program is less cost-effective than exercise treatment alone (Ketola et al 2009), and this was confirmed by Saltychev et al (2015). We have now analyzed the 140 impingement patients from our previous study (Ketola et al 2009) in subgroups to find out whether there is a subgroup of patients who would really benefit from arthroscopic acromioplasty.…”

“…We have already done a cost-effectiveness study that suggested that arthroscopic acromioplasty followed by a structural exercise program is less cost-effective than exercise treatment alone (Ketola et al 2009), and this was confirmed by Saltychev et al (2015). We have now analyzed the 140 impingement patients from our previous study (Ketola et al 2009) in subgroups to find out whether there is a subgroup of patients who would really benefit from arthroscopic acromioplasty. Secondly, we wanted to determine whether there is a subgroup in which the procedure should be avoided.…”

“…It has been shown that arthroscopic acromioplasty is not superior to a supervised exercise program (Ketola et al 2009, 2013, Papadonikolakis et al 2011, Diercks et al 2014, Saltychev et al 2015). However, arthroscopic acromioplasty has been increasingly used during the last decade (Paloneva et al 2015).…”