The recommendation from this review is that more high-quality trials are undertaken. A systematic review of the effectiveness of surgery was limited by the quality of evidence but their findings showed no difference between patients treated with surgery and those treated with non-surgical options. We searched NLH, Embase, MEDLINE, PEDro MetaRegister of Clinical Trials (active and archived registers),, Centre for Reviews and Dissemination (DARE, NHS EED and HTA), Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Studies databases, with the search terms “arthroscopy”, “arthroscopic”, “arthroscope”, “arthroscopies”, “acromioplasty”, “shoulder”, “rotator cuff”, “glenohumeral”, “acromioclavicular”, “supraspinatus”, “bicipital”, “subacromial”, “osteoarthritis”, “rheumatoid arthritis”, “calcific”, “tendonitis”, “impingement”, and “bursitis “. In 2009, we searched the scientific literature (assisted by Arthritis Research UK) before study submission with no language restrictions for reports published between 2000–09. The rationale is that the shoulder pain is caused by physical contact during arm movement between the rotator cuff tendons and a spur of bone or associated soft tissue projecting from the acromion of the scapula, and that surgical removal of the bone spur and soft tissue (decompression) eliminates this contact and, thereby cures or reduces symptoms. Subacromial decompression was introduced in 1972 as a treatment for subacromial shoulder pain without high-level evidence and is now one of the most common surgical procedures in orthopaedics. Shoulder pain is common and poses a substantial burden to society. There were six study-related complications that were all frozen shoulders (in two patients in each group). Both surgical groups showed a small benefit over no treatment (mean 29♴ points, mean difference vs decompression 2♸ points, p=0♰186 mean difference vs arthroscopy 4♲, p=0♰014) but these differences were not clinically important. Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months (decompression mean 32♷ points vs arthroscopy mean 34♲ points mean difference −1♳ points (95% CI −3♹ to 1♳, p=0♳141). At 6 months, data for the Oxford Shoulder Score were available for 90 patients assigned to decompression, 94 to arthroscopy, and 90 to no treatment. 24, 43, and 12 of the decompression, arthroscopy only, and no treatment groups, respectively, did not receive their assigned treatment by 6 months. Findingsīetween Sept 14, 2012, and June 16, 2015, we randomly assigned 313 patients to treatment groups (106 to decompression surgery, 103 to arthroscopy only, and 104 to no treatment). This trial has been registered at, number NCT01623011. The sample size calculation was based upon a target difference of 4♵ points (SD 9♰). The primary outcome was the Oxford Shoulder Score (0 to 48 ) at 6 months, analysed by intention to treat. Patients were followed up at 6 months and 1 year after randomisation surgeons coordinated their waiting lists to schedule surgeries as close as possible to randomisation. In the surgical intervention groups, patients were not told which type of surgery they were receiving (to ensure masking). We did the randomisation with a computer-generated minimisation system. Arthroscopy only was a placebo as the essential surgical element (bone and soft tissue removal) was omitted. We randomly assigned participants (1:1:1) to arthroscopic subacromial decompression, investigational arthroscopy only, or no treatment (attendance of one reassessment appointment with a specialist shoulder clinician 3 months after study entry, but no intervention). Exclusion criteria included a full-thickness torn rotator cuff. Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were eligible for arthroscopic surgery, and had previously completed a non-operative management programme that included exercise therapy and at least one steroid injection. We did a multicentre, randomised, pragmatic, parallel group, placebo-controlled, three-group trial at 32 hospitals in the UK with 51 surgeons.
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