The CSAW Study (Can Shoulder Arthroscopy Work?) - a placebo-controlled surgical intervention trial assessing the clinical and cost effectiveness of arthroscopic subacromial decompression for shoulder pain: study protocol for a randomised controlled trial

David Beard*, Jonathan Rees, Ines Rombach, Cushla Cooper, Jonathan Cook, Naomi Merritt, Alastair Gray, Stephen Gwilym, Andrew Judge, Julian Savulescu, Jane Moser, Jenny Donovan, Marcus Jepson, Caroline Wilson, Irene Tracey, Karolina Wartolowska, Benjamin Dean, Andrew Carr, Anthony Jones, Amar RanganJames Hutchinson, Veronica Conboy, Matthew Costa, Louise Stanton, Stephen Brealey, Megan Bowers

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

26 Citations (Scopus)
358 Downloads (Pure)

Abstract

Background: Arthroscopic subacromial decompression (ASAD) is a commonly performed surgical intervention for shoulder pain. The rationale is that removal of a bony acromial spur relieves symptoms by decompressing rotator cuff tendons passing through the subacromial space. However, the efficacy of this procedure is uncertain. The objective of this trial was to compare the efficacy and cost-effectiveness of ASAD in patients with subacromial pain using appropriate control groups, including placebo intervention. Methods/Design: The trial is a three-group, parallel design, pragmatic, randomised controlled study. The intervention content for each group (ASAD, active monitoring with specialist reassessment (AMSR) and investigational shoulder arthroscopy only (AO)) enables assessment of (1) the efficacy of the surgery against no surgery; (2) the need for a specific component of the surgery-namely, removal of the bony spur; and (3) quantification of the placebo effect. Concealed allocation was performed using a 1:1:1 randomisation ratio and using age, sex, baseline Oxford Shoulder Score (OSS) and centre as minimisation criteria. The primary outcome measure is the OSS at 6 months post randomisation. A total of 300 patients recruited over 24 months from a minimum of 14 UK shoulder units over 24 months were required to detect a difference of 4.5 points on the OSS (standard deviation, 9) with 90% power and to allow for 15% loss to follow-up. Secondary outcomes include cost-effectiveness, pain, complications and patient satisfaction. A substantial qualitative research component is included. The primary analysis will be conducted on the modified intention-to-treat analysis. Sensitivity analysis will be used to assess the robustness of the results with regard to the underlying assumptions about missing data using multiple imputation. Discussion: This trial uses an innovative design to account for the known placebo effects of surgery, but it also will delineate the mechanism for any benefit from surgery. The investigational AO group is considered a placebo intervention (not sham surgery), as it includes all components of subacromial decompression except the critical surgical element. Some discussion is also dedicated to the challenges of conducting placebo surgery trials. Trial registrations: UK Clinical Research Network UKCRN12104. Registered 22 May 2012.

Original languageEnglish
Article number210
Number of pages16
JournalTrials
Volume16
Issue number1
DOIs
Publication statusPublished - 9 May 2015

Structured keywords

  • Centre for Surgical Research

Keywords

  • Acromion
  • Arthroscopy
  • Placebo
  • Randomise
  • Sham
  • Shoulder
  • Trial
  • Waiting list

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