Surgery for shoulder impingement: a systematic review and meta-analysis of controlled clinical trials

Moin Khan; Bashar Alolabi; Nolan Horner; Asheesh Bedi; Olufemi R. Ayeni; Mohit Bhandari

doi:10.9778/cmajo.20180179

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Figure 1:
Selection of randomized controlled trials (RCTs) for inclusion in the meta-analysis.
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Figure 2:
Risk-of-bias assessment of randomized controlled trials included in the meta-analysis.
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Figure 3:
Pooled visual analogue scale pain (< 2 yr) outcomes of conservative and surgical treatment for shoulder impingement. Note: CI = confidence interval, IV = inverse variance, SD = standard deviation.
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Figure 4:
Pooled short-term (≤ 1 yr) functional outcomes of conservative and surgical treatment. Red lines show a zone of no important difference based on a minimal important difference of 10.4 points on the Constant–Murley score. Note: CI = confidence interval, IV= inverse variance. SD = standard deviation, Std. = standardized.
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Figure 5:
Pooled long-term (> 2 yr) functional outcomes of conservative and surgical treatment. Red lines show a zone of no important difference based on a minimal important difference of 10.4 points on the Constant–Murley score. Note: CI = confidence interval, IV = inverse variance, SD = standard deviation, Std. = standardized.

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Table 1:

Studies included in the meta-analysis

Study, year	Funding	Country	Patient characteristics		Treatment arm, no. of patients and description of treatment^*		Co-intervention	Major outcome measures	Crossover, %	Loss to follow-up, no. (%)

			Mean age, yr	Male sex, %	Conservative	Surgical
Brox et al., 199326	Non-industry	Norway	48	53	50: Supervised exercises 30: Placebo laser	45: Arthroscopic decompression	Postop physio (twice wkly increasing resistance exercises for 3–6 mo)	Neer score at 3, 6 mo; VAS	4	5 (4)

Peters et al., 199723	Not stated	Germany	58	64	40: Physiotherapy plus cortisone injection	32: Arthroscopic or open decompression	Postop physio	SSRS at 1, 2, 3, 4 yr	NR	NR

Rahme et al., 199827	Not stated	Sweden	42	45	21: Physiotherapy	21: Open decompression	Postop physio	VAS at 6, 12 mo	62	3 (7)

Brox et al., 199928	Non-industry	Norway	48	53	50: Supervised exercises 30: Placebo laser	45: Arthroscopic decompression	Postop physio (twice wkly increasing resistance exercises for 3–6 mo)	Neer score at 6 mo, 2.5 yr; VAS	33	15 (12)

Haahr et al., 200529	Non-industry	Denmark	44	31	45: Physiotherapy	45: Arthroscopic decompression	Postop physio (periscapular muscle and rotator cuff strengthening)	Constant score at 3, 6, 12 mo; PRIM score	13	6 (6.7)

Haahr et al., 200630	Non-industry	Denmark	44	31	45: Physiotherapy	45: Arthroscopic decompression	Postop physio (periscapular muscle and rotator cuff strengthening)	PRIM score at 4–8 yr	24	11 (12)

Ketola et al., 200931	Not stated	Finland	47	37	70: Exercise	70: Arthroscopic decompression	Postop physio (supervised therapy with increasing resistance for rotator cuff strengthening)	SDQ score at 2, 5 yr; VAS score	19.3	6 (4.2)

Ketola et al., 201332	Not stated	Finland	47	37	70: Exercise	70: Arthroscopic decompression	Postop physio (supervised therapy with increasing resistance for rotator cuff strengthening)	SDQ score at 2, 5 yr; VAS score	21	31 (22.1)

Farfaras et al., 201620	Not stated	Sweden	50	49	34: Physiotherapy	29: Arthroscopic decompression 24: Open decompression	Postop physio (gradual strengthening exercises)	Constant score at 2–3 yr; SF-36; Watson and Sonnebend score; ROM	16	9 (10.3)

Ketola et al., 201733	Not stated	Finland	47	37	70: Exercise	70: Arthroscopic decompression	Postop physio (supervised therapy with increasing resistance for rotator cuff strengthening)	SDQ score at 10 yr; VAS	21	50 (35.7)

Beard et al., 201824	Non-industry	United Kingdom	53	50	104: No treatment 103: Sham surgery (diagnostic arthroscopy)	106: Arthroscopic decompression	Postop physio (1–4 sessions)	Oxford shoulder score at 6,12 mo; Constant–Murley score; PainDETECT score; EQ5D; VAS; HADS	25	48 (15)

Farfaras et al., 201834	Not stated	Sweden	50	49	34: Physiotherapy	29: Arthroscopic decompression 24: Open decompression	Postop physio (gradual strengthening exercises)	Constant score at 10 yr; SF-36; Watson and Sonnebend score; ROM	9	13 (14.9)

Paavola et al., 201825	Non-industry	Finland	50	30	71: Supervised exercise 63: Sham surgery (diagnostic arthroscopy)	59: Arthroscopic decompression	Postop physio (gradual strengthening exercises)	VAS; Constant score; simple shoulder test; 15D	12	7 (3.6)

Note: EQ5D = EuroQol 5 dimensions score, HADS = Hospital Anxiety and Depression Score, postop physio = postoperative physiotherapy, SSRS = Subjective Shoulder Rating Scale, PRIM = Project on Research and Intervention in Monotonous Work score, ROM = range of motion, SDQ = Shoulder Disability Questionnaire score, SF-36 = Medical Outcomes Study 36-item Short Form, VAS = visual analogue scale; 15D = 15-dimensional score.
↵* The number of patients randomly assigned to each treatment arm.