Arthroscopic Shoulder Surgery Benefits May Not Outweigh Risks for Many Common Surgeries
While many surgeons question the evidence of regenerative treatments for common orthopedic injuries, some well done studies raise considerable questions and concerns for many common shoulder arthroscopic surgical procedures.
A recent article (July 2018) in the British Medical Journal compared patients who had surgery against those who did not for impingement symptoms. 210 patients with shoulder pain/impingement symptoms were randomized into three groups. One group had patients undergo sham (placebo) surgery where diagnostic arthroscopy was performed. The second group had actual subacromial decompression surgery. A third group was exercise only for shoulder impingement pain and symptoms. They studied outcomes for pain at rest and function (24 months) and found no significant difference between the sham surgery and decompression surgery. The exercise group did show selection bias in this study as it wasn’t truly blinded when compared to the decompression group. However, when compared to surgical complication and poor outcomes, exercise therapy was favored.
Based on this study, surgical decompression was not recommended. We now have additional studies showing the surgical management of shoulder pain favors physical therapy and or regenerative type procedures.
In another study, effectiveness of shoulder labral repair and bicep tenodesis (anchoring the bicep tendon to the humerus) was compared to sham surgery. This double blind study looked at 118 patients who had clinical symptoms and MRI arthrography indicating a labral tear. If arthroscopy evaluation revealed a superior labral (SLAP) tear, patients were randomly assigned to either 1) labral repair, 2) bicep tenodesis or 3) sham surgery. Outcomes were measured at 6 months and 24 months for pain, stability, change in symptoms and patient satisfaction including complications. There was no significant statistical difference in any follow-up outcome. Postoperative stiffness occurred in 5 patients with labral repair and 4 patients after tenodesis. The article concluded that arthroscopic surgery for labral repair or tenodesis was no better than sham surgery.
Total Shoulder Replacement Surgery
Another study looked at risk associated with total shoulder arthroplasty (replacement). The risk of serious adverse events was evaluated in 58,054 elective shoulder replacements in patients over age 50. The study looked at post-surgery complications at 30 days and 90 days. It also looked at revision rates (a 2nd procedure) at 3, 5, 10 and 15 years. They found revision rates to be 1 in 4 in men aged 55-59 years in the first 5 years after surgery. The risk of serious adverse events at 30 days post surgery was 1 in 28 and at 90 days 1 in 22. The adverse events followed were pulmonary embolism, myocardial infarction, respiratory tract infection, acute kidney injury, urinary tract infection and cerebrovascular event (stroke). 1 in 5 males aged 85 years and older experienced at least one serious adverse event within 90 days. Increased age, other medical issues and male sex were associated with significant increased risk.
The study concluded that younger aged men need to be aware of a higher likelihood of early failure resulting in more complex revision surgery. These risks may outweigh potential benefits, but overall, risk for surgery is higher than previously considered.
Surgery Versus Conservative Treatment for Rotator Cuff Repair
A study published in 2017 compared rotator cuff repair to physical therapy. This study showed minimal improvement when treated with rotator cuff repair as compared to those completing a physical therapy program. Although the study did show minimal improvement in the surgical group for pain reduction, it was considered to be of borderline clinical significance. The final conclusion was that a conservative approach should be favored as this group had fewer complications and adverse events. Further review of the literature suggests that for traumatic tears there is good outcome data, while degenerative tears as a group fared poorly with pain reduction and return of function.
As surgical management outcomes are being scrutinized against sham procedures, the evidence behind regenerative procedures becomes more compelling. Generally, regenerative procedures have low complication rates and good post procedural functional scores.
Although some patients will ultimately require surgery, a conservative approach should alway be the first line of treatment. After physical therapy and correction of underlying muscle imbalances, those with persistent pain should then consider whether a regenerative procedure would be beneficial versus surgical options. Stay tuned for further discussions on surgical benefits of knee arthroscopy versus a regenerative treatment in our next blog.