Arthroscopic surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome) Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes. Open versus arthroscopic subacromial decompression: analysis of one-year results. Open versus arthroscopic subacromial decompression: a prospective, randomized study of 34 patients followed for 8 years. 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. Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopic subacromial decompression versus open acromioplasty. [Bipolar shoulder prosthesis for rheumatoid arthritis with irreparable rotator cuff tear: results after 5 years' follow-up]. Arthroscopic versus open acromioplasty: a prospective, randomized, blinded study. Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized clinical trial. Comparison of an arthroscopic and an open procedure for posttraumatic instability of the shoulder: a prospective, randomized multicenter study.
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. 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. 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. 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. 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. To compare the effectiveness of ultrasound guided corticosteroid injection in the subacromial bursa with systemic corticosteroid injection in patients with rotator cuff disease.
                Double blind randomised clinical trial.
                Outpatient clinic of a physical medicine and rehabilitation department in Oslo, Norway. Patients 106 patients with rotator cuff disease lasting at least three months.
                Ultrasound guided corticosteroid and lidocaine injection in the subacromial bursa and lidocaine injection in the gluteal region (local group); corticosteroid and lidocaine injection in the gluteal region and ultrasound guided lidocaine injection in the subacromial bursa (systemic group).
                Difference in improvement in the overall shoulder pain and disability index score after six weeks.
                Six weeks after the intervention, the mean difference in improvement in overall shoulder pain and disability index score between the local group and the systemic group was -5.2 (95% confidence interval -13.9 to 3.5); it was -4.1 (-12.3 to 4.1, P=0.32) after adjustment for baseline score. A small but statistically significant difference in improvement between groups occurred in favour of the local group for two secondary outcome measures: the Western Ontario rotator cuff index (8.1, 0.7 to 15.6) and change in main complaint (2.0, 0 to 4).
                No important differences in short term outcomes were found between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease.
                Clinical trials NCT00640575. The purpose of this study was to compare the results of arthroscopic and open repair of isolated Bankart lesions of the shoulder using metallic suture anchors.
                Prospective randomized clinical study.
                Sixty patients with traumatic anterior shoulder instability underwent a surgical repair of an isolated Bankart lesion. The patients were divided into 2 groups of 30 patients each. In group 1, an arthroscopic repair was performed, and in group 2, an open procedure was performed. The groups were homogeneous for gender, age, dominance, number of dislocations, time elapsed between first dislocation and surgery, and pathologic findings. In all cases of both groups, the lesion was repaired using metallic suture anchors carrying nonabsorbable braided sutures. Postoperative rehabilitation was the same for the 2 groups. Two years' follow-up evaluation included Constant and Rowe shoulder scores. Statistical analysis of data was performed using an unpaired t test (significance for P <.05).
                No recurrence of dislocation of the involved shoulder has been reported in either group. Follow-up Constant and Rowe scores of the 2 groups were not significantly different. The only significant difference seen between the 2 groups was for range of motion evaluation with the Constant score. The mean value for group 1 (39.6 +/- 0.8) was significantly greater (P =.017) than that for group 2 (37.8 +/- 2.0).
                Arthroscopic repair with suture anchors is an effective surgical technique for the treatment of an isolated Bankart lesion. Open repair does not offer a significantly better 2-year result in terms of stability, and furthermore, can negatively affect the recovery of full range of motion of the shoulder.
                Level I. 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. The goal of this study was to assess the clinical and radiological outcome of bipolar shoulder prosthesis in twelve shoulders with rheumatoid arthritis (RA) and irreparable rotator cuff tears.
                The follow-up was more than five years (range 2-9 years). In addition, in order to investigate the effect of rheumatoid arthritis on outcome, results were compared with ten bipolar shoulder prostheses implanted for osteoarthritis with massive rotator cuff tears.
                The mean preoperative Constant score was 16.9 points with 2.6 points for pain, 4.2 points for activity, 9.5 points for motion and 0.6 points for force. The preoperative active motion was 63.8 degrees for forward flexion, 45 degrees for abduction and 12 degrees for active external rotation. At last follow-up, the average Constant score was 39.4 points with 10.7 points for pain, 10.8 points for activity, 13.8 points for motion and 4.1 points for force. Regarding the active motion, mean forward flexion was 83.7 degrees, 70.4 degrees for abduction and 29.1 degrees for external rotation. The complication rate was low, mainly superior migration due to infraspinatus tear and glenoid wear. Satisfactory deltoid arm level was achieved in all patients and no loosening was observed. Preoperative and postoperative scores of the rheumatoid group were not significantly different from the arthritis group (p<0.001).
                Our findings suggest that bipolar shoulder prosthesis provides a viable replacement alternative in RA combined with massive rotator cuff tear with a low rate of complication. Bipolar shoulder prosthesis demonstrates no clear superiority over conventional hemiarthroplasty regarding improved motion and glenoid wear. In addition, no significant difference with arthritis was observed (p<0.05), assuming that outcome depends principally on the preoperative condition of the rotator cuff.
                Some massive tears involving the subscapularis tendon can lead to anterior recurrence after bipolar shoulder prosthesis. They might be a limit to the procedure and require a reversed shoulder prosthesis or a glenohumeral arthrodesis. 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. Arthroscopic stabilization for anterior shoulder instability has been reported to result in a higher rate of recurrent instability compared to traditional open techniques.
                To test the null hypothesis that there is no difference in the clinical outcomes in patients with recurrent anterior shoulder instability treated with open or arthroscopic stabilization.
                Randomized controlled trial; Level of evidence, 1.
                A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Magnetic resonance arthrogram studies were obtained preoperatively. These findings were compared to arthroscopic findings. Postoperative evaluations included range of motion, stability, and subjective assessments including Single Assessment Numeric Evaluation, Simple Shoulder Test, Western Ontario Instability Index, and University of California, Los Angeles evaluation. Failure was defined as a second dislocation, recurrent subluxation, or symptoms precluding return to previous work or unrestricted active military duty.
                Sixty-one patients, 29 who received open stabilization and 32 who received arthroscopic stabilization, were evaluated at a mean of 32 months postoperatively (range, 24-48 months). Patient demographics were equivalent. Preoperative magnetic resonance arthrogram findings were confirmed at arthroscopic examination. The mean operative time was significantly shorter for the arthroscopic repairs (59 vs 149 minutes; P < .001). There were 3 clinical failures (2 open stabilizations, 1 arthroscopic stabilization) by the established criteria. There was a statistically significant improvement from preoperative to postoperative Single Assessment Numeric Evaluation scores in both groups (P < .001). The mean loss of motion (compared to the contralateral shoulder) was greater in the open shoulders. Subjective evaluations were equal in both groups. Conclusion: Clinical outcomes after arthroscopic and open stabilization were comparable. Preoperative magnetic resonance arthrograms in shoulders with anterior instability allow an accurate diagnosis of intra-articular abnormality that correlates well with operative findings. Arthroscopic stabilization for recurrent anterior shoulder instability can be performed safely; the clinical outcomes are comparable to those after traditional open stabilization. From 1993 through 1996, a multicenter study was conducted on the surgical treatment of patients with posttraumatic recurrent anterior shoulder dislocations. Fifty-six patients (40 men, 16 women; mean age 26 years [range 18-51 years]), were evaluated with shoulder arthroscopy. If a Bankart lesion was present, the patients were randomly allocated to either an arthroscopic reconstruction with the use of biodegradable tacks or an open reconstruction with suture anchors. The postoperative rehabilitation protocol for the two groups was identical. In all patients, the range of shoulder motion, stability, and the Constant and Rowe scores were evaluated at 3, 12, and 24 months postoperatively. Thirty patients were surgically treated with the arthroscopic technique and 26 patients with the open technique. In the arthroscopic group, there were recurrences in 7 (23%) of 30 patients at a mean of 13 months (range 5 to 21 months) after surgery. All patients with stable shoulders had a negative apprehension test result. In the open group, there were recurrences in 3 (12%) of 26 patients at a mean of 10 months (range 2 to 23 months) after surgery (P = not significant). In the arthroscopic group, 2 patients had new traumatic redislocations, whereas 1 patient redislocated during an epileptic seizure. In the open group, 1 traumatic redislocation occurred. The 2-year results in this study demonstrate a large number of redislocations after reconstruction, even in the open surgery group. Patient noncompliance with the rehabilitation protocol and predisposing disease may partially explain these results. A tendency was seen toward more redislocations in the arthroscopic group, which emphasizes the importance of correct patient selection and careful surgical technique in the difficult surgical procedure.
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.