Anterior acromioplasty. A comparison of two techniques

Surgery for rotator cuff disease

BACKGROUND

This review is one in a series of Cochrane reviews of interventions for shoulder disorders.

OBJECTIVES

To determine the effectiveness and safety of surgery for rotator cuff disease.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register, (The Cochrane Library Issue 1, 2006), MEDLINE, EMBASE, CINAHL, Sports Discus, Science Citation Index (Web of Science) in March 2006 unrestricted by date or language.

SELECTION CRITERIA

Only studies described as randomised or quasi-randomised clinical trials (RCTs) studying participants with rotator cuff disease and surgical interventions compared to placebo, no treatment, or any other treatment were included.

DATA COLLECTION AND ANALYSIS

Two independent review authors assessed methodological quality of each included trial and extracted data.

MAIN RESULTS

We included 14 RCTs involving 829 participants. Eleven trials included participants with impingement, two trials included participants with rotator cuff tear and one trial included participants with calcific tendinitis. No study met all methodological quality criteria and minimal pooling could be performed. Three trials compared either open or arthroscopic subacromial decompression with active non operative treatment (exercise programme, physiotherapy regimen of exercise and education, or graded physiotherapy strengthening program). No differences in outcome between these treatment groups were reported in any of these trials. One trial which also included a placebo arm (12 sessions detuned soft laser) reported that the Neer score of participants in both active treatment arms improved significantly more than those who received placebo at six months. Six trials that compared arthroscopic with open subacromial decompression reported no significant differences in outcome between groups at any time point although four trials reported a quicker recovery and/or return to work with arthroscopic decompression. Adverse events, which occurred in three trials and included infection, capsulitis, pain, deltoid atrophy, and reoperation, did not differ between surgical groups.

AUTHORS' CONCLUSIONS

Based upon our review of 14 trials examining heterogeneous interventions and all susceptible to bias, we cannot draw firm conclusions about the effectiveness or safety of surgery for rotator cuff disease. There is "Silver" (www.cochranemsk.org) level evidence from three trials that there are no significant differences in outcome between open or arthroscopic subacromial decompression and active non-operative treatment for impingement. There is also "Silver" level evidence from six trials that there are no significant differences in outcome between arthroscopic and open subacromial decompression although four trials reported earlier recovery with arthroscopic decompression.

Arthroscopic versus open acromioplasty: a systematic review

Prior to 1972, a variety of operations were performed to treat rotator cuff pain. Neer in 1972 recommended an anterior acromioplasty, which quickly became the standard of care based on Level IV and Level V evidence. In 1987, Ellman offered an arthroscopic approach to performing the acromioplasty; since then Level I studies have been conducted to assess the success of the arthroscopic approach. The purpose of our systematic review was to whether an arthroscopic approach to acromioplasty produces different outcomes (primary outcome pain relief) when compared to traditional open techniques. We performed a systematic literature review. We identified four Level I and one Level II randomized controlled prospective studies of four patient cohorts. While these studies had substantial flaws which could introduce bias, we found no differences between arthroscopic and open approaches for pain. Other outcomes that showed no difference in technique included UCLA shoulder scores, range of motion and strength. The data for the time required to perform surgery and the time to return to work for patients could not be used to recommend one approach over the other. Therefore, with the data available from four Level I and one Level II randomized controlled trials, we could not find appreciable differences between arthroscopic and open acromioplasty.