220 Ac a O hopaedica 2015; 86 (2): 220–224
Declining incidence o ac omioplas y in Finland
Juha Palone a1, esa lePola2, Ja o Ka PPinen3, Ja i Ylinen4, ille ÄÄ imaa5, and ille m ma ila6
1 Depa men o Su ge y, Cen al Finland Hospi al, Keskussai aalan ie 19, 40620 Jy äskylä, Finland; 2 Di ision o o hopedics and auma ology,
Depa men o auma, musculoskele al Su ge y and ehabili a ion, ampe e Uni e si y Hospi al, ampe e, Finland; 3 medical esea ch Cen e oulu, oulu
Uni e si y Hospi al and Uni e si y o oulu, oulu, Finland; 4 Depa men o Physical and ehabili a ion medicine, Cen al Finland Hospi al; 5 Depa men
o o hopaedics and auma ology, u ku Uni e si y Hospi al, u ku, Finland; 6 Depa men o Clinical Science, in e en ion and echnology, Ka olinska
ins i u e , Di ision o o hopedics and Bio echnology, Ka olinska ins i u e and Depa men o o hopedics a Ka olinska Uni e si y Hospi al Huddinge,
Sweden, and Depa men o o hopedics, ampe e Uni e si y, Finland.
Co espondence: juha.palone a@ksshp. i
Submi ed 2014-05-16. accep ed 2014-09-08.
Open Access - This a icle is dis ibu ed unde he e ms o he C ea i e Commons A ibu ion Noncomme cial License which pe mi s any noncomme cial use,
dis ibu ion, and ep oduc ion in any medium, p o ided he sou ce is c edi ed.
DOI 10.3109/17453674.2014.977703
Backg ound and pu pose — An inc eased incidence a e o
ac omioplas y has been epo ed; we analyzed da a om he
Finnish Na ional Hospi al Discha ge Regis e .
Pa ien s and me hods — Du ing he 14-yea s udy pe iod
(1998–2011), 68,877 ac omioplas ies wi hou o a o cu epai
we e pe o med on subjec s aged 18 yea s o olde .
Resul s — The incidence o ac omioplas y inc eased by 117%
om 75 o 163 pe 105 pe son yea s be ween 1998 and 2007. The
highes incidence was obse ed in 2007, a e which he incidence
a e dec eased by 20% o 131 pe 105 pe son yea s in 2011. The
incidence declined e en mo e a non-p o i public hospi als om
2007 o 2011. In con as , i con inued o ise a p o i -based p i-
a e o hopedic clinics.
In e p e a ion — We p opose ha his change in clinical p ac-
ice is due o accumula ing high-quali y scien i ic e idence ha
shows no di e ence in ou come be ween ac omioplas y and non-
su gical in e en ions o o a o cu disease wi h subac omial
impingemen synd ome. Howe e , he exac cause o he declining
incidence canno be de ined based solely on a egis y s udy. In e -
es ingly, his change was no obse ed a p i a e clinics, whe e he
numbe o ope a ions inc eased s eadily om 2007 o 2011.

Shoulde pain is one o he mos common musculoskele al
complain s, and o a o cu disease is conside ed he leading
cause o p olonged shoulde pain and disabili y (Mi chell e al.
2005). The ea men and mo bidi y o o a o cu diso de s
place a subs an ial economic bu den on socie y (Mi chell e al.
2005, Oh e al. 2007). Ro a o cu disease is classically con-
side ed o be a con inuum ha anges om acu e in lamma ion
o he endons o ull- hickness o a o cu ea (Nee 1983).
The e iology o o a o cu disease is mul i ac o ial, and i
has been a ibu ed o bo h ex insic and in insic mechanisms
(Sei z e al. 2011).
Ac omioplas y, i.e. subac omial decomp ession p oce-
du e, is he mos common su gical ope a ion pe o med on
he shoulde . The usual indica ion o ac omioplas y is Nee
s age-II o a o cu disease wi h subac omial pain o pa ial
ea o he sup aspina us o in aspina us endons (Chaudhu y
e al. 2010, Papadonikolakis e al. 2011). The ope a ion is pe -
o med by pa ially emo ing he an e io -in e io su ace o
he ac omion and he subac omial bu sa. The p ocedu e can be
pe o med using ei he an open app oach o an a h oscopic
app oach, which gi e simila esul s in he long e m (Da is e
al. 2010). The e ec i eness o su gical managemen o s age-
II impingemen has been ques ioned ecen ly. 3 high-quali y
andomized con olled ials (RCTs) compa ed a h oscopic
subac omial decomp ession o supe ised exe cises and ound
no s a is ically signi ican o clinically ele an di e ences
be ween su gical and non-su gical ea men (B ox e al. 1999,
Haah e al. 2005, Haah and Ande sen 2006, Ke ola e al.
2009, 2013). Ac omioplas y has also been used in combina-
ion wi h o a o cu epai o p o ec he epai ed endon,
al hough ecen ly i was shown ha he esul s o cu epai
a e simila wi hou ac omioplas y (Milano e al. 2007, Mac-
Donald e al. 2011).
A apid and con inuous inc ease in he incidence o ac omio-
plas y has been epo ed in selec ed pa ien coho s (Vi ale e
al. 2010, Yu e al. 2010, Papadonikolakis e al. 2011, Judge e
al. 2014), bu na ionwide incidence a es a e unknown. He e
we conduc ed a na ionwide hospi al discha ge egis e -based
s udy in Finland o assess whe he he incidence o ac omio-
plas y had changed om Janua y 1998 o Decembe 2011. Ou
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Ac a O hopaedica 2015; 86 (2): 220–224 221
hypo hesis was ha he o e all incidence o ac omioplas y
is inc easing. We also wan ed o assess whe he he change
in incidence a es in public/non-p o i hospi als and p i a e/
p o i -based hospi als a e simila .
Pa ien s and me hods
Design and se ing
We e iewed na ionwide da a om he Finnish Na ional Hos-
pi al Discha ge Regis e (NHDR) o he pe iod 1998–2011.
The Finnish Na ional Hospi al Discha ge Regis e (NHDR),
ounded in 1967, is an excellen da abase o epidemiologi-
cal s udies as i con ains da a on age, sex, domicile, ype o
hospi al (public o p i a e), leng h o hospi al s ay, p ima y
and seconda y diagnosis, and ope a ions pe o med du ing he
hospi al s ay. Da a collec ion o he Finnish NHDR is man-
da o y o hospi als, including all public and p i a e ins i u-
ions. The alidi y o he NHDR has been ound o be good
ega ding bo h he co e age and accu acy o da a (Ma ila e
al. 2008, Sund 2012, Hu unen e al. 2014).
S udy popula ion
All inhabi an s o Finland aged 18 yea s o olde we e included
in he s udy. The ope a i e ea men codes acco ding o he
Nomesco Classi ica ion o Su gical P ocedu es we e NBG10
( o an open ac omioplas y) and NBG15 ( o an a h oscopic
p ocedu e). Ac omioplas ies ha we e associa ed wi h ei he
open o a h oscopic o a o cu epai (p ocedu e code
NBL00) we e excluded om he analyses due o he second-
a y na u e o ac omioplas y compa ed o o a o cu epai .
Du ing he 14-yea s udy pe iod, 68,877 ac omioplas ies wi h-
ou concomi an o a o cu epai we e pe o med on pa ien s
aged 18 o olde .
S a is ics
The p ima y ou come a iable was he incidence o ac omio-
plas y pe 105 pe son yea s by age, sex, and s udy yea . To
compu e he incidence a es, he annual popula ion size was
ob ained om he O icial S a is ics o Finland, which is a
s a u o y, elec onic na ional popula ion egis e (S a is ics
Finland 2014). The incidence was based on he size o he
en i e popula ion o Finland aged 18 and olde a he han
on coho -based es ima es. Acco dingly, con idence in e als
we e no calcula ed. S a is ical analyses we e pe o med using
SPSS so wa e e sion 22.0.
E hics
E hics app o al was g an ed by he Finnish Na ional Ins i u e
o Heal h and Wellness (Dn THL/89/5.05.00/2012, da ed
Janua y 18, 2012).
esul s
Du ing he 14-yea s udy pe iod, he mean age o he pa ien s
a he ime o ope a ion was 52 (SD 10) yea s. The mean
age o men inc eased om 50 (SD 10) o 53 (SD 11) yea s,
and he mean age o women inc eased om 51 (SD 9) o 53
(SD 10) yea s. O e ime, he e was a consis en shi om
open ac omioplas y (64% o all ac omioplas ies in 1998) o
a h oscopic p ocedu es (93% in 2011). The mean leng h o
hospi al s ay was 1.3 (0–32) days.
Be ween 1998 and 2007, he incidence o ope a ions
inc eased om 75 o 163 pe 105 pe son yea s. A e 2007, he
incidence s a ed o decline, g adually eaching 131 pe 105
pe son yea s in 2011 (Figu e 1). The incidence a e in men
inc eased om 81 pe 105 pe son yea s in 1998 o 177 pe 105
pe son yea s in 2007, and hen declined o 149 pe 105 pe son
yea s in 2011. The co esponding igu es o women we e 69,
149, and 114, espec i ely. The male- o- emale a io was 1.2
(Figu e 1). Simila ends we e obse ed in he 18- o 64-yea -
old popula ion. The change in incidence o ac omioplas y was
less d ama ic in indi iduals aged 65 o olde (Figu e 2).
The incidence a es o ac omioplas y in public, non-p o i
hospi als peaked in 2007 a 137 pe 105 pe son yea s and
declined s eadily he ea e , o 100 pe 105 pe son yea s by
he end o 2011. In con as , he incidence in p o i -based hos-
pi als inc eased almos linea ly om 5 o 31 pe 105 pe son
yea s be ween 1998 and 2011 (Figu e 3). In he i s yea o
he s udy (1998), 93% o ac omioplas ies we e pe o med in
public hospi als and 7% we e pe o med in p i a e hospi als;
he co esponding pe cen ages in 2011 we e 76% and 24%.
Figu e 1. Incidence a es o ac omioplas y in Finland, by yea . Random-
ized con olled ials showing equal ou comes o ope a i e and nonop-
e a i e ea men o s age-II impingemen synd ome we e epo ed by
(a) B ox e al. (1999), (b) Haah e al. (2005), (c) Ke ola e al. (2005),
(d) Haah Ande sen (2006), and (e) Ke ola e al. (2009).
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222 Ac a O hopaedica 2015; 86 (2): 220–224
Discussion
Ou main inding was ha he o e all incidence o ac omio-
plas y inc eased s eadily and mo e han doubled be ween 1998
and 2007. A e 2007, he e was a 20% decline o 131 pe 105
pe son yea s in 2011. No ably, changes in he na ionwide
incidence a es o ac omioplas y ollowed he publica ion o
landma k ials showing ha he esul s o ope a i e and non-
ope a i e ea men o subac omial impingemen synd ome
a e equal. The incidence o ac omioplas y s a ed o decline
1–2 yea s a e pape s we e published by Haah and co-wo k-
e s (2005, 2006) and by Ke ola and co-wo ke s (2005). The
decline con inued ollowing publica ion o a s udy by Ke ola
e al. in 2009 (Figu e 1). I has been sugges ed ha a combina-
ion o scien i ic, o ganiza ional, and beha io al ac o s d i es
changes in clinical p ac ice (Fe lie e al. 1999). Howe e ,
he e we e no o ganiza ional o economic ac o s in Finland
du ing his ime pe iod ha would explain he en i e decline.
The e is e idence ha su gical a ia ion esul s mainly om
di e ences in physicians’ belie s abou he indica ions o su -
ge y, and he ex en o which pa ien p e e ences a e inco po-
a ed in o ea men decisions. A smalle deg ee o a ia ion
in egional su ge y a es is caused by di e ences in illness
bu den, diagnos ic p ac ices, and pa ien a i udes o medical
in e en ion (Bi kmeye e al. 2013). We he e o e p opose
ha o hopedic su geons a e inc easingly p ac icing e idence-
based medicine.
S eng hs and weaknesses
The s eng hs o ou s udy a e ha we used eliable na ionwide
da a and ha he s udy popula ion was he en i e adul popula-
ion o Finland. Because o his co e age o he en i e coun y,
including bo h public and p i a e hospi als, he changes in he
incidence o ac omioplas y a e ep esen a i e o na ionwide
clinical p ac ice and ends ega ding all ac i ely p ac icing
o hopedic su geons in Finland. Du ing he s udy pe iod, he e
we e no changes in diagnos ics, in he p e alence o o a o cu
disease, in coding o he su gical p ocedu es, o in he hospi al
egis y ha could explain he end obse ed. Al hough he
accu acy and co e age o he Finnish NHDR has been ound
o be excellen ega ding hip and knee diseases, he e is no
speci ic in o ma ion abou shoulde diso de s. Howe e , we
assume ha he co e age and accu acy a e no di e en om
wha is seen wi h knees and hips. A weakness o he s udy was
ha NHDR da a ha e no been alida ed in p i a e heal hca e.
Also, a con ounding ac o in he s udy was ha he egis y
da a did no allow us o de e mine i he e was a change in
he numbe o pa ien s wi h o a o cu disease who sough
ea men a public and p i a e heal hca e o ganiza ions du ing
he s udy pe iod. Ano he weakness is ha we a e unable o
p o e ha scien i ic e idence alone has caused he declining
incidence o ac omioplas y. The e may be o he ac o s ha
in luence a es o su ge y.
Rela ion o o he s udies
O he s ha e epo ed a con inuous inc ease in he incidence
o ac omioplas y in p e ious pa ien coho s. In a coho in
Minneso a, Yu e al. (2010) epo ed ha he incidence o
ac omioplas y inc eased o e ime om a es o 3 pe 105
pe sons in he pe iod 1980–1985 o 19 pe 105 pe sons in
2000–2005. Vi ale e al. (2010) s udied a coho in New Yo k
and epo ed ha he incidence o ac omioplas y bo h wi h
and wi hou o a o cu epai inc eased om 30 pe 105 in
1996 o 102 pe 105 in 2006. In a ecen s udy, he a e o
subac omial decomp ession ose om 5 o 40 pe 105 be ween
2000 and 2010 in NHS hospi als ac oss England (Judge e al.
2014). Simila ends o inc easing ac omioplas y incidence
ha e been epo ed using da a om he Flo ida Heal hca e
Cos and U iliza ion P ojec ’s S a e Ambula o y Su ge y
Da abase (HCUP SASD; 170 pe 105 pe son yea s in 2007)
Figu e 2. Incidence a es o ac omioplas y in Finland by yea , acco d-
ing o pa ien age.
Figu e 3. Incidence a es o ac omioplas y in Finland by yea , in non-
p o i and p o i heal hca e o ganiza ions.
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Ac a O hopaedica 2015; 86 (2): 220–224 223
and om he Cen e s o Medica e and Medicaid Se ices
(CMS) in he USA (95 pe 105 pa ien s o e 65 yea s o age,
in 2006) (Papadonikolakis e al. 2011). These s udies we e
based on highly selec ed samples, and ou s udy is he i s
o epo na ionwide incidence. The inc eased incidence a e
( om 75 o 163 pe 105 adul s pe yea ) in Finland is simi-
la o he a es epo ed using da a om he HCUP SASD
and CMS in he USA, bu i is subs an ially highe han a es
epo ed by o he s. He e we calcula ed he incidence a es
only o hose aged 18 yea s o olde . I he en i e popula-
ion had been included, he incidence a es would be app oxi-
ma ely 20% lowe , anging om 58 o 129 pe 105 pe son
yea s. I was easonable o exclude indi iduals younge han
18 yea s because he incidence o ac omioplas y in his popu-
la ion is e y low. To ou knowledge, we a e he i s o epo
a declining incidence o ac omioplas y. Judge e al. (2014)
epo ed an inc easing incidence in England du ing almos
he same ime pe iod. The easons o he obse ed a ia-
ion in incidence a e likely o be mul i ac o ial—including
pa ien -based, su geon-based, and sys ems-based ac o s.
Clinical implica ions and implica ions o socie y
App oxima ely hal o pa ien s who unde go ac omioplas y
due o o a o cu disease wi h shoulde impingemen syn-
d ome a e also ea ed using ac i e nonope a i e managemen
(Ylinen e al. 2013). Adhe ence o cu en ecommenda ions
o exe cise he apy has been ound o be insu icien in clini-
cal p ac ice (Ylinen e al. 2013). While cu en esea ch shows
ha ope a i e ea men is no mo e e ec i e han nonope a-
i e managemen , a nonope a i e app oach should be p e-
e ed (B ox e al. 1999, Haah e al. 2005, Haah and Ande -
sen 2006, Coghlan e al. 2008, Ke ola e al. 2009, Ke ola e
al. 2013). Se e al andomized, con olled s udies ha e shown
ha a p og essi e exe cise he apy egimen ha ocuses on
aining o he o a o cu and scapula muscles oge he wi h
speci ic s e ching exe cises is e ec i e in imp o ing shoulde
unc ion and in educing pain (Holmg en e al. 2012, K ome
e al. 2013, S uy e al. 2013). The mechanism is p esumed
o be ela ed o an inc eased ange o mo emen and s eng h,
which helps no malize scapulohume al unc ion.
Public heal hca e in Finland is p o ided by he commu-
ni y, and is open o e e y pe son a a minimal cos . Su geons
ecei e a ixed mon hly sala y. People a e also ee o use p i-
a e heal hca e, in which he cos s a e paid o by insu ance
companies, employe s, o by he pa ien s hemsel es; in his
sys em, su geons ecei e ex a ees o each ope a ion. In e es -
ingly, he change in he incidence o ac omioplas y du ing he
pas ew yea s has been bidi ec ional and appea s o be associ-
a ed wi h he ype o hospi al (non-p o i o p o i -based). A
ema kable downwa d end in he incidence o ac omioplas y
was obse ed in public, non-p o i heal hca e o ganiza ions,
whe eas he incidence con inues o ise a p i a e, p o i -based
heal hca e ins i u ions (a 490% inc ease o e 14 yea s). One
explana ion o hese con as ing ends is ha he e may ha e
been a change in he p opo ion o pa ien s seeking ea men
o shoulde p oblems in p i a e hospi als a he han public
hospi als. The absolu e numbe o ope a ions is likely o ise
i mo e pa ien s seek ea men a p i a e o hopedic clinics,
e en i he e a e no changes in he indica ions o su ge y. Fu -
he mo e, he Minis y o Social A ai s and Heal h in Finland
published uni o m c i e ia o e e al o non-eme gency ea -
men in public special heal hca e ega ding o a o cu disease
in 2009 (Minis y o Social A ai s and Heal h 2010). I is hus
possible ha some pa ien s may ha e been denied access o a
public hospi al h ough adop ion o he new guidelines, and
elec ed o be ea ed by he p i a e sec o ins ead. Howe e ,
he incidence o ac omioplas y s a ed o decline al eady in
2007, be o e hese guidelines we e a ailable. Ano he expla-
na ion is he possible in luence o inancial in e es s on clini-
cal p ac ice in p i a e hospi als, since he income o bo h he
hospi al and he o hopedic su geon is ela ed o he numbe
o ope a ions. In public hospi als, he e is no such ela ionship
be ween income and ope a ions.
Conclusions
We obse ed a declining incidence o ac omioplas y. The
exac eason o his change canno be de ined based on eg-
is y da a alone. This decline was no obse ed in p i a e
o hopedic clinics, whe e he incidence a es ha e con inued
o inc ease e en in ecen yea s. The possible in luence o he
ype o p ac ice (p o i o non-p o i ) on he decision o ec-
ommend su ge y o nonope a i e managemen o o a o cu
disease me i s u he in es iga ion.
JP: design o s udy, acquisi ion o da a, analysis and in e p e a ion o da a,
and w i ing o he manusc ip . VL: design o s udy, in e p e a ion o da a,
and c i ical e ision o he manusc ip . JK, JY, and VÄ: in e p e a ion o da a
and c i ical e ision o he manusc ip . VM: design o s udy, acquisi ion and
in e p e a ion o da a, and c i ical e ision o he manusc ip .
JP, VL, JK, JY, and VM ha e no compe ing in e es s o disclose. JK ecei ed
pe sonal ees om Abb ie, Mundipha ma, MSD, and UCB, un ela ed he
p esen wo k. This wo k was suppo ed by an Academy o Finland g an .
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