Subacromial decompression in patients with shoulder impingement with an intact rotator cuff: An expert consensus statement using the modified Delphi Technique comparing North American to European shoulder surgeons

Arthroscopy. 2021 Oct 13;S0749-8063(21)00889-6. doi: 10.1016/j.arthro.2021.09.031. Online ahead of print.

Abstract

Purpose: The purpose of this study was to perform a Delphi consensus for the treatment of patients with shoulder impingement with intact rotator cuff tendons, comparing North American to European shoulder surgeon preferences.

Methods: Nineteen surgeons from North America [NAP] and 18 surgeons from Europe [EP] agreed to participate and answered 10 open-ended questions in rounds 1 and 2. The results of the first two rounds were used to develop a Likert style questionnaire for round 3. If agreement at round 3 was <60% for an item, the results were carried forward into round 4. For round 4 the panel members outside consensus >60%, <80%) were contacted and asked to review their response. The level of agreement and consensus was defined as 80%.

Results: There was agreement on the following items: impingement is a clinical diagnosis; a combination of clinical tests should be used; other pain generators must be excluded; radiographs must be part of the work up; MR imaging is helpful; the first line of treatment should always be physiotherapy; a corticosteroid injection is helpful in reducing symptoms; indication for surgery is failure of non-operative treatment for a minimum of 6 months. The NAP were likely to routinely prescribe NSAIDs [NA 89%; EU 35%] and consider steroids for impingement [NA 89%. EU 65%].

Conclusion: Consensus was achieved for 16 of the 71 Likert items: impingement is a clinical diagnosis and a combination of clinical tests should be used. The first line of treatment should always be physiotherapy, and a corticosteroid injection can be helpful in reducing symptoms. The indication for surgery is failure of non-operative treatment for a minimum of 6 months. The panel also agreed that SAD is a good choice for shoulder impingement if there is evidence of mechanical impingement with pain not responding to non-surgical measures.

Keywords: Delphi technique; Subacromial decompression; consensus statement; shoulder arthroscopy; shoulder impingement.