Crusade against low value care continues

Hohmann et al. published a truly exceptional “Level V Guideline” in the Arthroscopy Journal. They conclude:

However, when indicated, SAD has stood the test of time and long-term studies have clearly demonstrated good and excellent outcomes.

So, two recent high-quality sham-controlled studies clearly demonstrate that arthroscopic subacromial decompression offers no relevant benefit over sham-surgery. Apparently we can ignore all this robust evidence since this procedure have “stood the test of time”. This is just unbelievable. Field of arthroscopic surgery claims to embrace EBM but this is everything but EBM. Guyatt et al. defined the “former paradigm” in medicine as follows:

1. Unsystematic observations from clinical experience are a valid way of building and maintaining one’s knowledge about patient prognosis, the value of diagnostic tests, and the efficacy of treatment.

2. The study and understanding of basic mechanisms of disease and pathophysiologic principles are a sufficient guide for clinical practice

Statements about “test of time” are exactly what the practice of medicine was prior to 1990 and the concept of EBM.

Poolman and van den Bekerom responded to this level V guideline and they wrote:

However, the burden of proof lies with those who claim that SAD is effective for treating long-lasting shoulder pain.

I could not agree more. One cannot ignore and distrust the best evidence we can have, namely sham-controlled RCTs simply by saying “they are biased”. You need to show the evidence which clearly shows that SAD improves outcome compared to non-operative treatment. It´s been almost five decades since modern joint arthroscopy was invented. We are still waiting this evidence.

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