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BMJ. 2019 Feb 6;364:l294. doi: 10.1136/bmj.l294.

Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline.

Author information

1
Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway.
2
Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
3
Finnish Center of Evidence based Orthopaedics (FICEBO), University of Helsinki, Helsinki, Finland.
4
Department of Orthopaedics and Traumatology, HUS Helsinki University Hospital, Helsinki, Finland.
5
Division of Physiotherapy, Linköping University, Linköping, Sweden.
6
School of Allied Health, La Trobe University, Melbourne, Australia.
7
Monash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University.
8
Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada.
9
Department of Physical Medicine and Rehabilitation, Oslo University Hospital and Faculty of Medicine, University of Oslo, Norway.
10
Dutch College of General Practitioners, Utrecht, The Netherlands.
11
Care and Public Health Research Institute, Department Family Medicine, Maastricht, The Netherlands.
12
Center of Gerontology and Geriatrics (National Clinical Research Center for Geriatrics), West China Hospital, Sichuan University, Chengdu, China.
13
Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
14
Department of Orthopaedic Surgery and Traumatology, Joint Research, OLVG, Amsterdam, The Netherlands.
15
Society for Participatory Medicine Member, USA.
16
MOH Holdings, 1 Maritime Square, Singapore.
17
Gryphenhübeliweg 28, 3006 Bern, Switzerland.
18
Canadian Arthritis Patient Alliance, Canada.
19
Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland.
20
Department of Orthopaedic Surgery and Traumatology, Joint Research, OLVG, Amsterdam, The Netherlands rwp@jointresearch.org.

Abstract

CLINICAL QUESTION:

Do adults with atraumatic shoulder pain for more than 3 months diagnosed as subacromial pain syndrome (SAPS), also labelled as rotator cuff disease, benefit from subacromial decompression surgery? This guideline builds on to two recent high quality trials of shoulder surgery.

CURRENT PRACTICE:

SAPS is the common diagnosis for shoulder pain with several first line treatment options, including analgesia, exercises, and injections. Surgeons frequently perform arthroscopic subacromial decompression for prolonged symptoms, with guidelines providing conflicting recommendations.

RECOMMENDATION:

The guideline panel makes a strong recommendation against surgery.

HOW THIS GUIDELINE WAS CREATED:

A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines and the GRADE system. The recommendation is based on two linked systematic reviews on (a) the benefits and harms of subacromial decompression surgery and (b) the minimally important differences for patient reported outcome measures. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of surgery in multilayered evidence summaries and decision aids available in MAGIC (www.magicapp.org) to support shared decisions and adaptation.

THE EVIDENCE:

Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options. Frozen shoulder may be more common with surgery.

UNDERSTANDING THE RECOMMENDATION:

The panel concluded that almost all informed patients would choose to avoid surgery because there is no benefit but there are harms and it is burdensome. Subacromial decompression surgery should not be offered to patients with SAPS. However, there is substantial uncertainty in what alternative treatment is best.

PMID:
30728120
DOI:
10.1136/bmj.l294
[Indexed for MEDLINE]
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Conflict of interest statement

Competing interests: All authors have completed the BMJ Rapid Recommendations interest disclosure form and a detailed, contextualised description of all disclosures is reported in appendix 1 on bmj.com. As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any financial conflict of interest. Professional and academic interests are minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions.

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