Prospective randomized surgical treatments for calcifying tendinopathy. Open versus arthroscopic subacromial decompression: a prospective, randomized study of 34 patients followed for 8 years. Open vs. arthroscopic acromioplasty: a prospective, randomized study. Arthroscopic subacromial decompression versus open acromioplasty. The subacromial impingement syndrome. A study of results of treatment with special emphasis on predictive factors and pain-generating mechanisms. Arthroscopic versus open acromioplasty: a prospective, randomized, blinded study. [Acromion resection for shoulder impingement syndrome. Results after an open and a percutaneous surgical method]. Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome) Open versus arthroscopic subacromial decompression: analysis of one-year results. Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes. The effect of suture materials and techniques on the outcome of repair of the rotator cuff: a prospective, randomised study. Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4-8-years' follow-up in a prospective, randomized study.
Thirty-eight patients with chronic calcifying tendinopathy of the shoulder were randomized prospectively into two groups: 19 patients had endoscopic decompression and 19 had open decompression. Thirty-three patients (19 with open and 14 with endoscopic decompression) were available for followup. Clinical and ultrasonographic investigations were done at followup. The purpose of the current study was to evaluate prospectively the clinical and sonographic results after open decompression and after endoscopic decompression. Apportionment of age and gender was similar in both groups. The followup was 15.7 months for patients after open decompression and 17.1 months for patients after endoscopic decompression. The average Patte score was 84.5 points (84.4 for patients who had endoscopic decompression and 84.6 for patients who had open decompression). Corresponding results were found with a Constant and Murley score of 96.6 points (97.6 for patients who had endoscopic decompression and 95.8 for patients who had open decompression). In the endoscopic group physiotherapy was recommended for 5 weeks more than in the open surgery group. Similar results were seen for the incapacity to work in both groups with 4.6 weeks for the patients who had endoscopic surgery and 5 weeks for the patients who had open surgery. No nerve injuries, wound infections, or other postoperative complications were found. Comparison of both surgical methods showed good clinical and score results. Endoscopic and open surgery are equally effective in the treatment of chronic calcifying tendinopathy. In a randomized prospective study, we selected 15 patients for arthroscopic subacromial decompression (ASD) and 19 patients for open subacromial decompression (OSD). All had impingement syndrome (Neer grade II), and had been unsuccessfully treated without surgery for more than 6 months. The UCLA Shoulder Rating Scale, Visual Analogue Scales for pain and satisfaction, isokinetic dynamometer recordings and physical testing were assessed preoperatively and at 1 (except isokinetic testing), 3, 6, and 12 months, and, finally, 8 years after surgery. We found essentially no differences in the clinical tests between the groups during this period. The use of ASD or OSD seems to be a matter of cosmesis and personal preference. Between May 1988 and May 1990, 44 patients with Stage II impingement were randomized into open and arthroscopic treatment groups. Forty-one patients were available for final follow-up in May 1991: 22 in the open group, 19 in the arthroscopic group. Comparisons of pain, function, motion, and strength were made preoperatively and at 2, 6, 12, 26, and 52 weeks postoperatively. Final analysis showed that the main benefits of arthroscopic acromioplasty were evident in the first 3 months postoperatively. Arthroscopic patients regained flexion and strength more rapidly than did open patients, had shorter hospitalizations, used less narcotics, and returned more quickly to both work and activities of daily living. By 3 months postoperatively, open patients tended to "catch up" with arthroscopic patients, and further recovery was equivalent. In both groups, full recovery took at least 1 year for the majority of patients and in both groups at 1 year > 90% of patients achieved a satisfactory result. Because of its medical and economic advantages for both the patient and the health-care system, we conclude that arthroscopic acromioplasty should become the procedure of choice for patients with impingement syndrome refractory to conservative treatment. A random prospective comparison was conducted of 20 patients who underwent arthroscopic subacromial decompression or open acromioplasty as treatment for impingement syndrome. The Neer anterior acromioplasty served as comparison in the evaluation to arthroscopic technique. The comparison shows more rapid rehabilitation and better range of motion in the arthroscopic group. Time of surgery is also shorter for arthroscopy than for the open technique. Arthroscopic subacromial decompression appears to be superior to open acromioplasty as a treatment for impingement syndrome. Forty-two patients with subacromial impingement syndrome entered a randomized prospective study comparing open anterior acromioplasty with a physiotherapy regime. The criterion for a successful outcome of treatment was a reduction of the initial pain score of more than 50% using the visual analogue scale (VAS) technique. The evaluation was performed by an independent observer. At the 6-month follow-up, treatment in the surgical group had been successful in 12/21 (57%) patients versus 6/18 (33%) in the physiotherapy group. A one-year evaluation revealed 16/21 (76%) "successes" in the surgical group. A direct and unbiased comparison with the physiotherapy group was not possible at one year, since 13 patients chose surgery after initial physiotherapy. However, in "an intention to treat" analysis outcome at one year was significantly better in those randomized to surgery. We found two standardized, composite, active movements--the "Pour out of a Pot" manoeuvre requiring the emptying of a pot of water, and the "Hand in Neck" manoeuvre--to be of predictive value for the outcome of surgery. When combining three pain-related variables into a criterion for prediction of success, a sensitivity of 78% (p < 0.02) and a specificity of 90% (p < 0.03) were attained. We advance the hypothesis that pain in the impingement syndrome is mainly elicited by comparison of the subacromial bursa. In some patients a traction-responsive pain generator in the supraspinatus tendon may be present as well. The purpose of this study is to determine whether arthroscopic acromioplasty is equivalent or superior to open acromioplasty, in a prospective, randomized, controlled, blinded clinical trial. Seventy-one patients with a clinical diagnosis of impingement syndrome were randomized to arthroscopic or open acromioplasty. Nine were excluded because of full-thickness rotator cuff tears diagnosed after randomization. Sixty-two patients (49 men and 13 women) with a minimum follow-up of 12 months (mean, 25 months) were included. The patient groups were virtually identical with regard to duration of symptoms, shoulder functional demands, age, sex, hand dominance, mechanism of onset, range of motion, strength, joint laxity, and the presence of a compensation claim. Patients were prospectively randomized to arthroscopic or open acromioplasty after stratification for age (>50 years),associated ligamentous laxity, and the presence of an ongoing compensation claim. The main outcome measure was visual analog scales for pain and function. Also recorded were UCLA shoulder scores and visual analog scales for postoperative improvement, patient satisfaction, and a variety of clinical measures. An independent blinded examiner assessed all patients. There was no significant difference between open and arthroscopic acromioplasty in visual analog scales for postoperative improvement (P =.30), patient satisfaction (P =.94), UCLA shoulder score (P =.69), or strength (P =.62); however, open was superior to arthroscopic acromioplasty for pain and function (P =.01). Overall, 67% of patients had a good or excellent result. This increased to 87% when unsettled compensation claims were excluded. Repeat (open) acromioplasty was performed in 5 patients in the unsuccessful arthroscopic group without improvement. Open acromioplasty was equivalent to arthroscopic acromioplasty for UCLA scores and patient satisfaction. For pain and function, both gave significant improvement but the open technique may be superior. Unsettled compensation is a predictor of poor outcome. Anterior acromioplasty as described by Neer has been an effective procedure for shoulder impingement syndrome. Artroscopic acromioplasty is regarded as a technically demanding procedure. Since 1988 we have developed a closed percutaneous acromioplasty using motorized instruments. The purpose of this randomised clinical trial was to compare the results of open and closed percutaneous acromioplasty. We found a significant improvement in shoulder score, but no differences between the group treated with the open procedure and the group treated with the closed procedure. To compare the effectiveness of arthroscopic surgery, a supervised exercise regimen, and placebo soft laser treatment in patients with rotator cuff disease (stage II impingement syndrome).
                Randomised clinical trial.
                Hospital departments of orthopaedics and of physical medicine and rehabilitation.
                125 patients aged 18-66 who had had rotator cuff disease for at least three months and whose condition was resistant to treatment.
                Arthroscopic subacromial decompression performed by two experienced surgeons; exercise regimen over three to six months supervised by one experienced physiotherapist; or 12 sessions of detuned soft laser treatment over six weeks.
                Change in the overall Neer shoulder score (pain during previous week and blinded evaluation of function and range of movement by one clinician) after six months.
                No differences were found between the three groups in duration of sick leave and daily intake of analgesics. After six months the difference in improvement in overall Neer score between surgery and supervised exercises was 4.0 (95% confidence interval -2 to 11) and 2.0 (-1.4 to 5.4) after adjustment for sex. The condition improved significantly compared with placebo in both groups given the active treatments. Treatment costs were higher for those given surgery (720 pounds v 390 pounds).
                Surgery or a supervised exercise regimen significantly, and equally, improved rotator cuff disease compared with placebo. The results of open subacromial decompression (OSD) were compared with arthroscopic subacromial decompression (ASD) after 1 year in 32 subjects (4 bilateral), and the correlation between the two shoulder rating scales for impingement was documented. Patients were evaluated clinically on the modified University of California at Los Angeles (UCLA) shoulder rating scale, and Constant scale. Scapular position and rotation were evaluated as well as a rotation and abduction shoulder strength test using the Cybex II dynamometer. No parameters revealed significant differences between the groups, except for the UCLA score which indicated an advantage for the ASD group (p = 0.046). The OSD group scored 24.5 (5.45) on the UCLA scale and 73.8 (18.9) on the Constant scale, whereas the ASD group scored 28.3 (5.6) and 80.8 (16.4). To study the correlation between both scales, the Pearson correlation product-moment coefficient was calculated and a high correlation (r = 0.81) obtained. Less mobility was found in the operated arm for all parameters, with the exception of glenohumeral abduction in both groups and passive elevation in the OSD group. Only in the OSD group did the scapula in the operated extremity show more abduction of the inferior angle of the scapula. Weaker abduction strength in the operated side was found in the ASD group, whereas in the OSD group there was significantly less adduction and external rotation strength at 180 degrees/s en 240 degrees/s. We conclude that after one year the open group tends to catch up with the arthroscopic patients and that the main benefits after arthroscopic surgery as described in literature are more evident in the shorter period. We performed a prospective, randomized study to determine whether arthroscopic subacromial decompression changes the outcome of rotator cuff repair. We performed a power analysis to ensure statistical validity. Patients scheduled for arthroscopic rotator cuff repair were randomized to cuff repair with arthroscopic subacromial decompression (group 1) or without it (group 2). All other aspects of the surgical and postsurgical treatment were identical. We included patients with full-thickness tears limited to the supraspinatus tendon and a type 2 acromion. We excluded patients with prior surgery, those with larger tears involving two or more tendons, those with a type 1 or 3 acromion, those with workers' compensation claims, and those who had concomitant procedures (labral repair, acromioclavicular joint resection) There were 47 patients in group 1 and 46 in group 2. Minimum follow-up was 1 year (mean, 15.6 +/- 3.3 months). We recorded the American Shoulder and Elbow Surgeons (ASES) shoulder scores preoperatively and postoperatively. There was no statistical difference in postoperative ASES scores between group 1 (91.5 +/- 10.3) and group 2 (89.2 +/- 15.1) (P =.392). The change in ASES score over time did not differ between the two groups (61.1 vs 60.2, P =.363). In conclusion, within the parameters described above, arthroscopic subacromial decompression does not appear to change the functional outcome after arthroscopic repair of the rotator cuff. In a prospective, randomised study on the repair of tears of the rotator cuff we compared the clinical results of two suture techniques for which different suture materials were used. We prospectively randomised 100 patients with tears of the rotator cuff into two groups. Group 1 had transosseous repair with No. 3 Ethibond using modified Mason-Allen sutures and group 2 had transosseous repair with 1.0 mm polydioxanone cord using modified Kessler sutures. After 24 to 30 months the patients were evaluated clinically using the Constant score and by ultrasonography. Of the 100 patients, 92 completed the study. No significant statistical difference was seen between the two groups: Constant score, 91% vs 92%; rate of further tear, 18% vs 22%; and revision, 4% vs 4%. In cases of further tear the outcome in group 2 did not differ from that for the intact repairs (91% vs 91%), but in group 1 it was significantly worse (94% vs 77%, p = 0.005). Overall, seven patients had complications which required revision surgery, in four for pain (two in each group) and in three for infection (two in group 1 and one in group 2). To compare the prognosis of subacromial impingement (SAI) stage II treated conservatively or with subacromial decompression.
                A follow-up study after 4-8 years in a randomized controlled trial (RCT) with 90 adult cases with SAI treated in a Danish hospital from 1996 to 2000 with graded physiotherapy and exercises or arthroscopic subacromial decompression. Outcomes were proportion of time per year with income transfers (indexed 0-1), including total transfers (marginalization), sick leave and disability pension obtained from the registry at the Ministry of Work. Self-reported function, working capability, employment status and global improvement were obtained by questionnaire in September 2004. The main outcomes are given as differences in development from baseline.
                Seventy-nine (88%) responded to the questionnaire and registry data were obtained from 81. After 1 year the marginalization index increased by 0.45 [95% confidence interval (CI) 0.35-0.56] for surgery and 0.25 (0.16-0.34) for physiotherapy. Cases undergoing surgery also tended to have more sick payments during the first year, but the difference was not significant. Four years after inclusion, changes in indices did not differ between treatment groups. Self-reported outcomes after 4-8 years did not differ between treatment groups.
                The results of surgical decompression were equal to those of conservative treatment, and the surgery group had more income transferrals during the first year of follow-up.
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.