Protocol for a randomised controlled trial of Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS)

Research output: Contribution to journalArticle


  • Andrew Metcalfe
  • Elke Gemperle Mannion
  • Helen Parsons
  • Jaclyn Brown
  • Nicholas Parsons
  • Josephine Fox
  • Rebecca Kearney
  • Tom Lawrence
  • Howard Bush
  • Kerri McGowan
  • Iftekhar Khan
  • James Mason
  • Charles Hutchinson
  • Nigel Stallard
  • Martin Underwood
  • Stephen Drew

Colleges, School and Institutes

External organisations

  • University Hospitals Coventry and Warwickshire NHS Trust
  • University of Warwick Library, University of Warwick
  • f Patient representative.


INTRODUCTION: Shoulder pain due to irreparable rotator cuff tears can cause substantial disability, but treatment options are limited. A balloon spacer is a relatively simple addition to a standard arthroscopic debridement procedure, but it is costly and there is no current randomised trial evidence to support its use. This trial will evaluate the clinical and cost-effectiveness of a subacromial balloon spacer for individuals undergoing arthroscopic debridement for irreparable rotator cuff tears.New surgical procedures can provide substantial benefit to patients. Good quality randomised controlled trials (RCTs) are needed, but trials in surgery are typically long and expensive, exposing patients to risk and the healthcare system to substantial costs. One way to improve the efficiency of trials is with an adaptive sample size. Such methods are well established in drug trials but have rarely, if ever, been used in surgical trials.

METHODS AND ANALYSIS: Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS) is a participant and assessor blinded, adaptive, multicentre RCT comparing arthroscopic debridement with the InSpace balloon (Stryker, USA) to arthroscopic debridement alone for people with a symptomatic irreparable rotator cuff tear. It uses a group sequential adaptive design where interim analyses are performed using all of the 3, 6 and 12-month data that are available at each time point. A maximum of 221 participants will be randomised (1:1 ratio), this will provide 90% power (at the 5% level) for a 6 point difference in the primary outcome; the Oxford Shoulder Score at 12 months. A substudy will use deltoid-active MRI scans in 56 participants to assess the function of the balloon. Analysis will be on an intention-to-treat basis and reported according to principles established in the Consolidated Standards of Reporting Trials statement.

ETHICS AND DISSEMINATION: NRES number 18/WM/0025. The results will be disseminated via peer-reviewed publications, presentations at conferences, lay summaries and social media.


Bibliographic note

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.


Original languageEnglish
Article numbere036829
Number of pages9
JournalBMJ open
Issue number5
Publication statusPublished - 21 May 2020


  • adult orthopaedics, clinical trials, shoulder

ASJC Scopus subject areas