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. 2019 Mar 7;7(1):E149-E158.
doi: 10.9778/cmajo.20180179. Print 2019 Jan-Mar.

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

Moin Khan  1 , Bashar Alolabi  2 , Nolan Horner  2 , Asheesh Bedi  2 , Olufemi R Ayeni  2 , Mohit Bhandari  2
Affiliations

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

Moin Khan et al. CMAJ Open. .

Abstract

Background: Shoulder impingement is one of the most common nontraumatic upper limb causes of disability in adults. Our aim was to evaluate the efficacy of surgical intervention in comparison with nonoperative or sham treatments in patients with shoulder impingement in terms of both pain and functional outcomes.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials. Two reviewers independently screened MEDLINE, Embase, PubMed and Cochrane databases for randomized controlled trials published from 1946 to July 19, 2018. A risk-of-bias assessment was conducted for all included studies, and outcomes were pooled using a random effects model. The primary outcome was improvement in pain up to 2 years. Secondary outcomes were functional outcome scores reported in the short term (≤ 1 yr) and long term (≥ 2 yr). Heterogeneity was assessed using the I 2 statistic. Functional outcome scores were presented along with minimal clinically important differences to provide clinical context for findings.

Results: Thirteen randomized controlled trials (n = 1062 patients) were included in this review. Eligible patients had a mean age of 48 (standard deviation ± 4) years and 45% were men. The pooled treatment effect of surgical intervention for shoulder impingement did not demonstrate any benefit to surgery with respect to pain relief (mean difference -0.07, 95% CI -0.40 to 0.26) or short-term functional outcomes (standardized mean difference -0.09, 95% confidence interval [CI] -0.27 to 0.08). Surgical intervention did result in a small statistically significant but clinically unimportant improvement in long-term functional outcomes (standardized mean difference 0.23, 95% CI 0.06 to 0.41).

Interpretation: Evidence suggests surgical intervention has little, if any, benefit for impingement pathology in the middle-aged patient. Further research is required to identify those patients who will reliably benefit from surgical intervention as well as optimal conservative treatment strategies.

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Conflict of interest statement

Competing interests: Asheesh Bedi reports personal fees from Arthrex outside the submitted work. Olufemi Ayeni reports personal fees from Smith & Nephew and ConMed outside the submitted work. Mohit Bhandari reports personal fees from AgNovos Healthcare, Sanofi Aventis, Smith & Nephew and Stryker and grants from DJ Orthopedics and Ferring Pharmaceuticals outside the submitted work. No other competing interests were declared.

Figures

Figure 1:
Figure 1:
Selection of randomized controlled trials (RCTs) for inclusion in the meta-analysis.
Figure 2:
Figure 2:
Risk-of-bias assessment of randomized controlled trials included in the meta-analysis.
Figure 3:
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.
Figure 4:
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.
Figure 5:
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.
See this image and copyright information in PMC

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