No difference in long-term development of rotator cuff rupture and muscle volumes in impingement patients with or without decompression.

Background and purpose - Arthroscopic acromioplasty is still commonly used in the treatment of shoulder impingement syndrome, even though its benefits are questioned; randomized controlled studies have not shown any benefits when compared to non-operative treatment. In this randomized study, we investigated whether operative treatment protects from later rotator cuff rupture and whether it has any effect on the development of rotator cuff muscle volume. Patients and methods - 140 stage-II impingement patients were randomized to a structured exercise group (n = 70) or to an operative group (n = 70). In the operative group, arthroscopic acromioplasty was performed, after which a similar structured exercise program was begun. MRI of the shoulder was done at baseline and at 5 years. Results - There were no statistically significant differences in either the amount of perforating ruptures of the supraspinatus tendon or in the changes in muscle volume at 5 years. The grading of muscle fatty degeneration showed worse results in the operative group, but this difference was not statistically significant. Interpretation - In this study, we found that arthroscopic acromioplasty does not have any long-term benefit based on radiological findings of muscle volumes. Also, the frequency of later rotator cuff rupture was similar irrespective of whether or not surgery was performed. Acromioplasty is not justified as a treatment for dynamic shoulder impingement syndrome.

Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment?

BACKGROUND AND PURPOSE: Shoulder impingement syndrome is common, but treatment is controversial. Arthroscopic acromioplasty is popular even though its efficacy is unknown. In this study, we analyzed stage-II shoulder impingement patients in subgroups to identify those who would benefit from the operation. PATIENTS AND METHODS: In a previous randomized study, 140 patients were either treated with a supervised exercise program or with arthroscopic acromioplasty followed by a similar exercise program. The patients were followed up at 2 and 5 years after randomization. Self-reported pain was used as the primary outcome measure. RESULTS: Both treatment groups had less pain at 2 and 5 years, and this was similar in both groups. Duration of symptoms, marital status (single), long periods of sick leave, and lack of professional education appeared to increase the risk of persistent pain despite the treatment. Patients with impingement with radiological acromioclavicular (AC) joint degeneration also had more pain. The patients in the exercise group who later wanted operative treatment and had it did not get better after the operation. INTERPRETATION: The natural course probably plays a substantial role in the outcome. Based on our findings, it is difficult to recommend arthroscopic acromioplasty for any specific subgroup. Regarding operative treatment, however, a concomitant AC joint resection might be recommended if there are signs of AC joint degeneration. Even more challenging for the development of a treatment algorithm is the finding that patients who do not recover after nonoperative treatment should not be operated either.

Long-term results after surgery for gastric cancer with or without jejunal reservoir: results of surgery for gastric cancer in Kanta-Häme central hospital in two consecutive periods without or with jejunal pouch reconstruction in 1985-1998.

BACKGROUND: Gastric cancer still has a disease-specific 5-yr survival less than 30% and an overall survival of about 15%. The quality of life of patients who undergo gastrectomy is poor owing both to the severity of the disease itself and to the mutilation of the upper gastrointestinal channel after the reconstruction. Therefore, the combination of a jejunal pouch with gastrectomy has been claimed to improve the life quality and nutritional status of these patients. AIM: To assess the clinical results after surgery for gastric cancer in two consecutive periods with or without jejunal-pouch reconstruction. METHODS: 271 consecutive patients referred for surgery for gastric cancer in 1985-1991 (116 patients) and in 1992-1998 (155 patients) in Kanta-Häme central hospital were retrospectively analyzed regarding their disease, mode of surgery, and the immediate and long-term results. In the former observation period gastrectomy was performed with Roux-en-Y esophagojejunostomy without a reservoir, and in the latter period this procedure was combined with a jejunal reservoir. The data were collected from patient journals and from the death certificate obtained from the National Centre of Statistics in Finland. RESULTS: During the study period the incidence of cancer in the cardia increased among the surgical patients from 13.1 to 26.7% (p <0.05). Despite this proximal migration, the cancer-specific 5-yr survival remained practically unchanged during the two study periods, 29.4% and 32.2% (NS). During the period of jejunal-pouch reconstruction there were non-significant increases of the incidences of local recurrence (from 18.9% to 26.5%), of immediate postoperative anastomotic fistulae (from 0.9% to 4.5%) as well as of the immediate mortality (from 2.6% to 3.7%) (NS for each). CONCLUSIONS: Despite proximal migration of gastric cancer and the application of a jejunal reservoir, the long-term as well as the immediate results after curative surgery (i.e., D2-gastrectomy) for gastric cancer have remained relatively unchanged. The jejunal-pouch reconstruction with the present technique after gastrectomy can therefore be safely applied.