National Trends Show Declining Use of Arthroscopic Subacromial Decompression Without Rotator Cuff Repair

doi:10.1016/j.arthro.2021.05.019

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 37, Issue 12, December 2021, Pages 3397-3404

https://doi.org/10.1016/j.arthro.2021.05.019 Get rights and content

Purpose

The goal of this study was to investigate trends in the United States for arthroscopic subacromial decompression (aSAD) and open SAD (oSAD) with and without rotator cuff repair (RCR) between 2010 and 2018.

Methods

The PearlDiver Mariner claims database was queried using CPT codes for open and arthroscopic subacromial decompression and rotator cuff repair. Patient cohorts were developed for those undergoing aSAD or oSAD between 2010 and 2018, then segmented by whether RCR was performed simultaneously. Annual incidence was analyzed, as were associated diagnosis codes, and concomitant shoulder-associated procedures performed on the same day.

Results

The PearlDiver Mariner dataset from 2010 to 2018 included 186,932 patients that underwent aSAD, while 9,263 patients underwent oSAD. The total incidence of aSAD declined from 118.0 to 71.3 per 100,000 (39.6% decrease) (P < .001). This change was due primarily to a decreasing incidence of aSAD performed without RCR, which declined from 66.3 to 25.5 per 100,000 (61.5% decrease) (P < .001). During the same period, the incidence of aSAD combined with RCR remained relatively stable, from 51.7 to 45.8 per 100,000 (11.5% decrease) (P = .27). The overall incidence of oSAD declined from 7.1 to 2.2 per 100,000 (68.1% decrease) (P < .001).

Conclusions

The overall rate of aSAD has declined in recent years, primarily due to a large decrease in the incidence of aSAD without RCR as an isolated treatment for rotator cuff disorders.

Clinical Relevance

Prior studies have demonstrated a rising incidence of SAD; however, high-level clinical evidence and clinical practice guidelines have challenged its efficacy. It is important for orthopaedic surgeons to understand evolving national trends in management among their peers.

Introduction

Rotator cuff disorders, including subacromial impingement, bursitis, and partial- and full-thickness rotator cuff tears, are the most common underlying cause of shoulder pain.1, 2, 3, 4 The prevalence of rotator cuff tears has been estimated to range from 44% to 85%, depending on the age and setting of the population.4, 5, 6, 7, 8, 9 Surgical treatments for rotator cuff disorders have changed over time based on an evolving understanding of the potential etiologies, including intrinsic tendon degeneration and extrinsic mechanical impingement of the acromion, coracoacromial ligament (CAL), and subacromial bursa.¹⁰^,¹¹ The acromioplasty was developed by Neer in 1972 and modified to include arthroscopic acromioplasty, CAL release and subacromial bursal tissue excision by Ellman in 1987 (arthroscopic subacromial decompression, or aSAD).¹²^,¹³ Since that time, aSAD has become one of the most common orthopaedic surgeries, performed either in isolation or in conjunction with a rotator cuff repair, to alleviate extrinsic tendon compression.14, 15, 16, 17

However, emerging and accumulating evidence has questioned the efficacy of aSAD as a surgical treatment for rotator cuff disorders.¹⁸ As an isolated treatment for stage I and II subacromial impingement syndrome (without rotator cuff tear), aSAD has shown variable results, with several randomized controlled trials in the short-term (≤2 year) showing no benefit compared to physical therapy (PT) or placebo, and in the longer-term (∼10 year), showing mixed results.19, 20, 21, 22, 23 As an adjunct to rotator cuff repair (RCR), SAD has also shown mixed benefits, with multiple studies showing no benefit from its addition.24, 25, 26

Several epidemiologic studies published between 2010 and 2012 demonstrated a substantially rising incidence of SAD between 1980 and 2005 with conflicting data between 2005 and 2009.¹⁷^,²⁷^,²⁸ Internationally, multiple investigations have shown variable trends in SAD surgery with rising rates in England and Korea, and declining incidences in Finland and Scotland.⁸^,29, 30, 31, 32 Simultaneously, while SAD trends locally and internationally received attention, trends in RCR within the United States were investigated, demonstrating an increasing overall incidence and an increasing preference toward arthroscopic surgery in place of open surgery.¹⁵

The goal of this study was to investigate trends in the United States for aSAD and open subacromial decompression (oSAD) with and without RCR between 2010 and 2018 in response to the changing paradigm questioning the efficacy of SAD. We hypothesized that rates of open oSAD and aSAD without RCR would decrease, while rates of aSAD performed with arthroscopic RCR (aRCR) would increase or remain constant over the same time frame.

Section snippets

Data Source

The Mariner dataset of the PearlDiver research database (PearlDiver Technologies, Colorado Springs, CO) was used to query deidentified, administrative claims data from patients covered by commercial insurance, Medicare Advantage, Medicaid, and/or claims paid with cash. It includes roughly 122 million total patients and spans the years of 2010 to 2018. The data within this database is Health Insurance Portability and Accountability Act (HIPPA) compliant and deemed exempt from institutional

Results

Through the Mariner database, 196,195 patients were identified that underwent 202,511 SADs performed over the study period from 2010 to 2018. Of the SAD surgeries performed, 193,226 (95%) were arthroscopic, while 9,285 (5%) were open. Of the aSAD surgeries, 105,756 (55%) were performed concurrently with an arthroscopic RCR (aRCR), while 87,470 (45%) underwent aSAD without an associated aRCR (Table 1). Demographics of the aSAD and oSAD patient cohorts are presented in Table 1. As some patients

Discussion

These results demonstrate a significant decrease in the overall incidence of aSAD from 2010 to 2018, a roughly 39.6% decrease, driven primarily by a large decline in the incidence of aSAD performed independently of RCR. Specifically, the annual incidence of aSAD without RCR decreased by over 61.5% between 2010 and 2018, while the rate of aSAD associated with RCR remained relatively stable. The proportion of aSAD performed with RCR increased from 43.9% to 64.2% between 2010 and 2018.

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Surgeons Factors and Trends Associated with the Use of Subacromial Decompression at the Time of Rotator Cuff Repair
2024, Journal of Hand Surgery
Subacromial decompression (SAD) has historically been described as an essential part of the surgical treatment of rotator cuff disorders. However, investigations throughout the 21st century have increasingly questioned the need for routine SAD during rotator cuff repair (RCR). Our purpose was to assess for changes in the incidence of SAD performed during RCR over a 12-year period. In addition, we aimed to characterize surgeon and practice factors associated with SAD use.
Records from two large tertiary referral systems in the United States from 2010 to 2021 were reviewed. All cases of RCR with and without SAD were identified. The outcome of interest was the proportion of SAD performed during RCR across years and by surgeon. Surgeon-specific characteristics included institution, fellowship training, surgical volume, academic practice, and years in practice. Yearly trends were assessed using binomial logistic regression modeling, with a random effect accounting for surgeon-specific variability.
During the study period, 37,165 RCR surgeries were performed by 104 surgeons. Of these cases, 71% underwent SAD during RCR. SAD use decreased by 11%. The multivariable model found that surgeons in academic practice, those with lower surgical volume, and those with increasing years in practice were significantly associated with increased odds of performing SAD. Surgeons with fellowship training were significantly more likely to use SAD over time, with the greatest odds of SAD noted for sports medicine surgeons (odds ratio = 3.04).
Although SAD use during RCR appears to be decreasing, multiple surgeon and practice factors (years in practice, fellowship training, volume, and academic practice) are associated with a change in SAD use.
These data suggest that early-career surgeons entering practice are likely driving the trend of declining SAD. Despite evidence suggesting limited clinical benefits, SAD remains commonly performed; future studies should endeavor to determine factors associated with practice changes among surgeons.
Opioid prescription trends after ambulatory anterior cervical discectomy and fusion
2023, Spine Journal
Opioid utilization has been well studied for inpatient anterior cervical discectomy and fusion (ACDF). However, the amount and type of opioids prescribed following ambulatory ACDF and the associated risk of persistent use are largely unknown.
To characterize opioid prescription filling following single-level ambulatory ACDF compared with inpatient procedures.
Retrospective cohort study.
Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database.
Rate, amount, and type of perioperative opioid prescription.
Opioid-naive patients who underwent ambulatory (no overnight stay) or inpatient single-level ACDF from 2011 to 2019 were identified from a national insurance database. Perioperative opioids were defined as opioid prescriptions 30 days before and 14 days after the procedure. Rate, amount, and type of opioid prescription were characterized. Multivariable analyses controlling for any differences in demographics and comorbidities between the two treatment groups were utilized to determine any association between surgical setting and persistent opioid use (defined as the patient still filling new opioid prescriptions >90 days postoperatively).
A total of 42,521 opioid-naive patients were identified, of which 2,850 were ambulatory and 39,671 were inpatient. Ambulatory ACDF was associated with slightly increased perioperative opioid prescription filling (52.7% vs 47.3% for inpatient procedures; p<.001). Among the 20,280 patients (47.7%) who filled perioperative opioid prescriptions, the average amount of opioids prescribed (in morphine milligram equivalents) was similar between ambulatory and inpatient procedures (550 vs 540, p=.413). There was no association between surgical setting and persistent opioid use in patients who filled a perioperative opioid prescription, even after controlling for comorbidities, (adjusted odds ratio, 1.15, p=.066).
Ambulatory ACDF patients who filled perioperative opioid prescriptions were prescribed a similar amount of opioids as those undergoing inpatient procedures. Further, ambulatory ACDF does not appear to be a risk factor for persistent opioid use. These findings are important for patient counseling as well as support the safety profile of this new surgical pathway.
Editorial Commentary: Denial of Payment Limits Patient Access to Musculoskeletal Procedures: What Can Willie Sutton Teach Us About the Decreasing Incidence of Acromioplasty?
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
Arthroscopic acromioplasty is one of the most commonly performed orthopedic surgical procedures. The indication for performing an acromioplasty has traditionally been based on the mechanical theory of impingement of the coracoacromial arch on the soft tissues of the rotator cuff footprint. Orthopedic surgeons have recommended surgically decompressing this phenomenon for six decades to eliminate shoulder pain and restore function. Recent high-level studies have cast doubt on the value of acromioplasty compared to other nonoperative treatment modalities. There is also an increased recognition and awareness that rotator cuff disease is as much a degenerative and senescent process as it is a mechanical one. There is now good evidence that the incidence of acromioplasty is falling significantly, especially in treatment scenarios that involve an intact rotator cuff. The cause of this decrease must be understood as multifactorial and related to both the clinical evidence and the economics and reimbursement policy concerning acromioplasty. Like many other high-volume and elective orthopedic surgical procedures, third-party reimbursement policy dictates patient access to treatments. Yet, current and future literature and clinical expertise determine proper indications for acromioplasty. Doctors are in the best position to indicate proper patient care.
Holistic, conservative treatment of subacromial syndrome in rotator cuff tendinopathy
2022, Obere Extremitat
International impact of large multi-centre surgical trials of arthroscopic subacromial decompression
2021, medRxiv

: The authors report the following potential conflicts of interest or sources of funding: L. L. Shi received personal fees from Depuy and Arthrex, outside of submitted work. J. A. Strelzow reports consultant fees from Sytnes and Accumed, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

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Original ArticleNational Trends Show Declining Use of Arthroscopic Subacromial Decompression Without Rotator Cuff Repair

Purpose

Methods

Results

Conclusions

Clinical Relevance

Introduction

Section snippets

Data Source

Results

Discussion

Clin Biomech

Clin Biomech

J Arthrosc Relat Surg

Arthrosc J Arthrosc Relat Surg

J Shoulder Elb Surg

Lancet

J Arthrosc Relat Res

Arthroscopy

Indications for rotator cuff repair: A systematic review

Clin Orthop Relat Res

Shoulder pain: Diagnosis and management in primary care

Br Med J

Subacromial impingement syndrome

J Am Acad Orthop Surg

Shoulder disorders in general practice: incidence, patient characteristics, and management

Ann Rheum Dis

Shoulder disorders in general practice: Prognostic indicators of outcome

Br J Gen Pract

Shoulder pain in a community-based rheumatology clinic

Br J Rheumatol

Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England

Bone Joint J

Diagnosis and relation to general health of shoulder disorders presenting to primary care

Rheumatology

Rotator cuff degeneration: Etiology and pathogenesis

Am J Sports Med

Anterior acromioplasty for the chronic impingement syndrome in the shoulder

J Bone Jt Surg

National trends in rotator cuff repair

J Bone Jt Surg Ser A

Practice patterns for subacromial decompression and rotator cuff repair

J Bone Jt Surgery

Management of rotator cuff injuries

J Am Acad Orthop Surg

Original Article
National Trends Show Declining Use of Arthroscopic Subacromial Decompression Without Rotator Cuff Repair