Is acromioplasty necessary in the setting of full-thickness rotator cuff tears? A systematic review

BackgroundThe benefits of acromioplasty in treating rotator cuff disease have been debated. We systematically reviewed the literature regarding whether acromioplasty with concomitant coracoacromial(CA) release is necessary for the successful treatment of full-thickness rotator cuff tears.ResultsFour studies fulfilled the inclusion criteria. They reported on 354 patients (mean age, 59 years; range 3–81 years) with a mean follow-up of 22 months (range 12–24 months). There were two level-I and two level-II studies. Two studies compared rotator cuff repair with versus without acromioplasty, and two studies compared rotator cuff repair with versus without subacromial decompression (acromioplasty, CA ligament resection, and bursectomy). The procedures were performed arthroscopically, and the CA ligament was released in all four studies. There were no statistically significant differences in clinical outcomes between patients treated with acromioplasty compared with those treated without acromioplasty.ConclusionsThis systematic review of the literature does not support the routine use of partial acromioplasty or CA ligament release in the surgical treatment of rotator cuff disease. In some instances, partial acromioplasty and release of the CA ligament can result in anterior escape and worsening symptoms. Further research is needed to determine the optimum method for the operative treatment of full-thickness rotator cuff tears.

Level of evidence

Level I, systematic review of level I and II studies.     

Surgical decompression of the fornix humeri, comparison of 2 procedures: resection of the ligament and Neer's method of anterior acromioplasty

The impingement-syndrome is caused by a conflict between the humeral head, the rotator cuff and the coracoacromial arch. Degenerative changes in the rotator cuff appear to be the cause when conservative treatment fails, surgical decompression may be resorted to. The two methods commonly applied are the resection of the coracoacromial ligament and Neer's anterior acromioplasty. In this retrospective study 52 patients were followed up of whom 31 had ligament resection and 21 had acromioplasty. The average follow up time was 10 months. Excellent and good results were achieved by ligament resection in 16 patients (52%) and by acromioplasty in 12 patients (57%). Satisfactory results had 10 (32%) patients after ligament resection and 8 patients (38%) after acromioplasty. In 5 cases (16%) unsatisfactory results were achieved by ligament resection and in 1 case (5%) after acromioplasty. Statistically the results did not differ at the 5% level of error. Both methods retain the length of the acromion which is important as it is the attachment of the deltoid muscle and determines the functional lever arm of this muscle. The superior results of acromioplasty in cases with rotator tears suggest that this procedure could be beneficial as a routine decompression in these cases. Theoretically the acromioplasty creates more space for the reconstructed cuff.     

The influence of distal clavicle resection and rotator cuff repair on the effectiveness of anterior acromioplasty

Anterior acromioplasty, described by Neer in 1972, is generally accepted as the procedure of choice for symptomatic subacromial impingement. Subsequent authors have written little about the prolonged length of postoperative rehabilitation, residual strength deficits, and the effect of the addition of a distal clavicle resection and/or rotator cuff repair. The authors reviewed 50 patients with late Neer Stage II and Stage III impingement lesions who were treated with anterior acromioplasty. In addition to the acromioplasty, 13 shoulders had a distal clavicle resection, nine had a rotator cuff repair, and ten had a distal clavicle resection and rotator cuff repair. The average patient age was 53 years (range, 36-70 years), and the average duration of symptoms was 43 months. Overall, 92% of the patients were graded as good or excellent on the basis of pain relief, strength, range of motion, and ability to resume full activity. Prolonged rehabilitation was noted in all groups, averaging 8.5 months; however, patients with a distal clavicle resection and rotator cuff repair required a 25% longer rehabilitation before full activity was obtained. A residual strength deficit was also noted in 70% of the patients requiring cuff repairs versus 50% in the patients with intact cuffs. Pain relief was equally obtained in all groups.     

Contact pressure and glenohumeral translation following subacromial decompression: how much is enough?

Subacromial decompression is a common surgical procedure that has historically included coracoacromial ligament resection. However, recent reports have advocated preserving the coracoacromial ligament to avoid the potential complication of anterosuperior escape. The optimal subacromial decompression would achieve a smooth coracoacromial arch and decreased rotator cuff contact pressures while preserving the function of the arch in glenohumeral stability. We hypothesized that a subacromial decompression with a limited acromioplasty with preservation of the coracoacromial ligament can decrease extrinsic pressure on the rotator cuff similar to a coracoacromial ligament resection, without altering glenohumeral translation. Three different subacromial decompressions, including a "smooth and move," a limited acromioplasty with coracoacromial ligament preservation, and a coracoacromial ligament resection, were performed on 6 cadaveric specimens with intact rotator cuffs. Glenohumeral translation and peak rotator cuff pressure during abduction were recorded. No change in translation was observed after a smooth and move or a limited acromioplasty. Compared to baseline specimens, anterosuperior translation was increased at 30° of abduction following coracoacromial ligament resection (P<.05). Baseline rotator cuff pressure was greatest during abduction with the arm in 30° of internal rotation. Peak rotator cuff pressure decreased up to 32% following a smooth and move, up to 64% following a limited acromioplasty, and up to 72% following a coracoacromial ligament resection. Based on the present study, a limited acromioplasty with coracoacromial ligament preservation may best provide decompression of the rotator cuff while avoiding potential anterosuperior glenohumeral translation.     

The lift-up osteotomy of the acromion. A new technique in the treatement of the impingement syndrome, especially in connection with the repair of rotator cuff tears

Summary There are many different causes leading to impingement lesions of the shoulder (e. g., architecture of the acromion, arthritis of the acromioclavicular joint, bursitis subacromialis, chronic instability). There are also different ways of treating it. Neer described his technique of anterior acromioplasty in 1972. With this technique there is sometimes a limitation in the amount of resection possible because of the anatomical findings (i. e., very curved or small acromion). We developed a new technique: the lift-up osteotomy of the acromion (LOA). This technique allows us to gain as much subacromial space as needed (e. g., for large anterior deltoid flaps). Osteotomy of the acromion gives an excellent view of the rotator cuff. Even large lesions can easily be repaired. After the cuff repair is done, the acromion is refixed with two canulated screws. So far, we have used this LOA technique in more than 100 patients in impingement operations, cuff repairs and anterior deltoid flaps all with good results.      

Editorial Commentary: Classic Arthroscopic Anterolateral Acromioplasty Does Not Translate to Clinically Meaningful Differences in Lateral Acromial Overcoverage

Despite its time-honored tradition, the classic Neer acromioplasty has come under increased scrutiny in the recent literature, particularly when performed in the absence of rotator cuff repair. The American Medical Association Current Procedural Terminology Committee has transitioned the acromioplasty procedure, and definition of the related Current Procedural Terminology code 29827, to a procedure that is “added-on” to shoulder arthroscopy. Several authors have sought to investigate the true value of arthroscopic subacromial decompression for extrinsic sources of impingement. Common indications for acromioplasty include bursal-sided tears, prominent type III hooked acromial morphology, calcified coracoacromial ligament, and severe rotator cuff tendinopathy. However, the classic arthroscopic acromioplasty may not meaningfully address lateral outlet impingement and acromial overcoverage, as measured by an elevated critical shoulder angle or acromial index, thereby leading to persistent abduction impingement and mechanical abrasion. In these cases, lateral acromial resection of up 5 to 10 mm may be preferentially considered to decrease the pathologic critical shoulder angle (>35°) and reduce the risk of primary or secondary rotator cuff tendon failure.     

Arthroscopic subacromial decompression

In 1983, Ellman reported the first subacromial decompression by arthroscopy as an alternative to open acromioplasty which described by Neer in 1972. Subacromial decompression combinates a removing of the antero lateral part of the acromion, a release of the coraco acromial ligament and a subacromial bursectomy. The principal indication is a chronic anterior impingement after failure to medical treatment. This subacromial decompression can be associated to cuff debridement, cuff repair, tenotomy or tenodesis of the biceps tendon or repair intraarticular lesion (SLAP, labrum...). The contraindications are massive cuffs tear with a superior migration of the humeral head or if the acromion is flat. Then, acromioplasty and release of the CA ligament could create a superior and anterior migration of the humeral head responsable to a pseudo paralytic shoulder. If we compare to open acromioplasty, arthroscopic decompression has some advantages; no split deltoid or desinsertion of anterior deltoid fibers, small cicatrices, less postoperative pain allowing immediate physiotherapy and possibility to explorate and to repair intra articular lesion during the same operation.     

Impingement syndrome of the shoulder. 50 cases treated by Neer's anterior acromioplasty

The authors present the preliminary results of 50 cases of impingement syndrome treated surgically using an operative technique which at least included an anterior Neer acromioplasty. Surgery was performed after a period of progression ranging from several months to several years. These included 2 Neer stage 1 (4%), 29 stage II (58%) and 19 stage III (38%). In all cases an anterior Neer acromioplasty was carried out. In 18 cases, an additional procedure was also performed (resection of the acromial extremity of the clavicle, suture of a rotator cuff rupture, resection reinsertion of the long head of biceps and an Apoil and Augereau deltoid flap procedure). Results could be assessed in 48 cases (2 cases lost to follow up). They demonstrated 31 very good (i.e. 64.5%), 12 good results (i.e. 25%) and 5 poor results (i.e. 10.5%).     

Rehabilitation following anterior acromioplasty

The shoulder region is one of the most challenging part of the human body to rehabilitate. Postoperative days following anterior acromioplasty are painful, with a high potential course of developing soft tissue fibrosis and joint contracture. In the past, following anterior acromioplasty and/or rotator cuff repair, the rehabilitation process was usually delayed for up to four to six weeks to allow healing of the repaired site. This conservative rehabilitation approach resulted in significant restrictions in glenohumeral and scapular joint mobility, weakness of the shoulder girdle musculature, prolonged pain, and functional limitations. Currently the trend of rehabilitation following anterior acromioplasty shifted toward a more earlier and aggressive approach thanks to improved surgical and soft tissue fixation techniques and advances in arthroscopic procedures. This has allowed active-assisted shoulder motion immediately after subacromial decompression and rotator cuff surgery. The rehabilitation team following anterior acromioplasty of the shoulder should consist of the physiatrist, orthopedic surgeon, physical therapist, and the patient.     

Operative release of the impingement syndrome

We examined the long-term results of two different methods of shoulder decompression (Neer acromioplasty and resection of the coracoacromial ligament) after an average observation period of 8 years. Clinical and radiological features were evaluated in 48 patients with 50 treated shoulders, as was the subjective result of the treatment in 58 patients with 61 operated joints. Pain was substantially eased in 93% (acromioplasty) and 100% (ligamentary resection), mobility improved in 76% and 83%, respectively. A favourable result was achieved in 86% of the acromioplasty cases and in 75% of the ligament resection cases. In one-third of the shoulders, an increasing degeneration of joint structures could be demonstrated radiologically; the degree depended on the severity of the initial rotator cuff injury, not on the method of shoulder decompression. The differences between both surgical methods examined were not statistically significant, but acromioplasty provides a superior extension of the subacromial space and protection for the reconstructed rotator cuff tendons. Our results compare favourably with other published studies. The methods described are suitable for the treatment of subacromial impingement.     

Operations for impingement of the shoulder. Early results in 52 patients

This is a prospective study of 52 consecutive patients with impingement syndrome of the shoulder who underwent an anterior acromioplasty according to Neer with rotator cuff repair and/or a resection of the lateral end of the clavicle added where it was indicated. There was a full-thickness tear in 14 cases. The follow-up was 11 months. The overall results were excellent-good in 40 patients and fair-poor in 12 patients. If two out of three of the following criteria were present, the patient had an increased risk for a fair or poor result: age greater than 50 years, sick leave greater than 6 months, or an associated cervical problem.     

Arthroscopic subacromial decompression: analysis of one- to three-year results

Arthroscopic subacromial decompression (ASD) is a method of performing anterior acromioplasty utilizing basic arthroscopic techniques. The procedure is indicated in cases of chronic impingement syndrome that have failed to respond to prolonged conservative management. The purpose of this study is to present an analysis of the 1- to 3-year follow-up results of the initial 50 consecutive cases of ASD that I have performed. Forty (80%) of the cases had advanced stage II impingement without rotator cuff tear. Ten (20%) had full-thickness tears of the rotator cuff. Patients were evaluated pre and postoperatively on the UCLA Shoulder Rating Scale, which includes an assessment of pain, function, range of motion (ROM), strength, and patient satisfaction. Eighty-eight percent of the cases were rated "satisfactory" (excellent or good), and 12% were rated "unsatisfactory" (fair or poor). The procedure is technically demanding, and to achieve a satisfactory result the criteria of open anterior acromioplasty must be met. Arthroscopic subacromial decompression is presented as an alternative to open anterior acromioplasty in advanced stage II and selected cases of stage III impingement syndrome.     

Decompressive surgery in the tendinitis and tear stages of rotator cuff disease

Eighty-six shoulders with rotator cuff disease (54 with tendinitis and 32 with rotator cuff tear stage) operated on to relieve the impingement exerted by the coracoacromioclavicular arch on the rotator cuff were analyzed. The median follow-up time was 5.0 years. Partial resection of the anterior undersurface of the acromion, excision of the coracoacromial ligament or of the lateral end of the clavicle (and most commonly a combination of all three measures), were the methods used to achieve decompression. The final results show a substantial improvement in 83% of the cases. The results were related to the extent of acromial resection, preoperative range of the painful arc, and age ; but no statistically significant prognostic signs could be determined. There was some evidence, however, that a wide painful arc and extensive resection of the acromion were associated with a poor outcome. The indications for clavicular resection remain somewhat uncertain. Clavicular resection combined with acromioplasty seemed to give somewhat fewer good results, but the procedure is nevertheless indicated in cases with subacromial impingement associated with acromioclavicular osteoarthrithis. Decompressive surgery proved to be as effective in the tendinitis stage of the disease as in the case of rotator cuff tear. Conclusive operative release of shoulder impingement in rotator cuff disease is a useful procedure in patients with painful arc symptoms resistant to conservative treatment. The result can be improved by refinement of both indications and techniques.     

Open anterior acromioplasty with preservation of the coracoacromial ligament: A modified surgical technique

The importance of the preservation of the subacromial arch has been stressed recently, especially in irreparable lesions of the rotator cuff to prevent anterosuperior migration of the humeral head. The purpose of this article is to describe the surgical technique of a modified open anterior acromioplasty performed through an intra-acromial osteotomy that increases the subacromial space and preserves the insertion of the coracoacromial ligament on the undersurface of the acromion. To compare this new technique with classical acromioplasty, a prospective but nonrandomized study was performed including 20 patients undergoing open anterior acromioplasty and 22 patients undergoing a modified open anterior acromioplasty. At a mean follow-up of 18 months, no differences related to shoulder function as evaluated by the Constant score were found between these two groups. This modified acromioplasty increases the subacromial space, preserving the anatomy of the subacromial arch, and provides functional results as good as those obtained with classical open acromioplasty.     

Biomechanics of coracoacromial arch modification

Although the biomechanics of the coracoacromial arch and coracoacromial ligament (CAL) morphology are well studied, to our knowledge, the biomechanics of the coracoacromial arch after CAL resection and medial reattachment have not yet been studied. The purpose of this report is to examine the biomechanical consequences of coracoacromial arch alteration and subsequent reconstruction in cadaveric specimens. Anterosuperior humeral head translation was measured after the application of an anterosuperior 150-N load under 5 sequential scenarios: (1) intact CAL, (2) subperiosteal CAL release, (3) standard acromioplasty, (4) CAL reconstruction, and (5) modified Neer acromioplasty. A significant decrease in anterosuperior migration was found after CAL reconstruction compared with both anterior acromioplasty (P = .038) and modified Neer acromioplasty (P = .01). Thus, in patients with massive rotator cuff tears, reconstruction of the CAL may provide the necessary stabilizing force to prevent excessive anterosuperior translation and possible humeral head escape from the coracoacromial arch.     

Postoperative subcoracoid impingement syndrome in patients with rotator cuff tear

Impingement of the tendinous rotator cuff on the coracoid process (subcoracoid impingement syndrome) has rarely been reported as a cause of pain after surgery for rotator cuff tear. We evaluated clinical features, surgical results, and histopathology findings of resected coracoid processes in patients with subcoracoid impingement syndrome after anterior acromioplasty and management of rotator cuff tear. Pain at the anterior aspect of the shoulder, localized tenderness of the coracoid process, anterior shoulder pain on horizontal adduction testing, and positive subcoracoid block suggest subcoracoid impingement syndrome. Postoperative subcoracoid impingement syndrome was investigated in 11 of 216 cases with rotator cuff surgery. The average patient age at the time of surgery was 61.2 y (range, 28-78 y). Coracoplasty (partial resection of the posterolateral side of the coracoid process) was performed in 9 shoulders that had not responded to a 6-month regimen of conservative treatment. Complete pain relief was achieved in all cases. Histopathologic findings revealed hypertrophic changes of the fibrocartilage layer at the posterior aspect of the resected coracoid process. We concluded that subcoracoid impingement syndrome was an important factor in unsuccessful rotator cuff surgery and recommend that coracoplasty be performed on patients with symptoms of subcoracoid impingement syndrome after management of the rotator cuff tear.     

Is Acromioplasty Ever Indicated During Rotator Cuff Repair?

Based on data from a national healthcare insurance carrier in the United States between 2010 and 2012, orthopedic surgeons performed an acromioplasty procedure on 73 to 76% of their arthroscopic rotator cuff repairs. This has remained a prevalent arthroscopic adjunct despite the controversies disputing the role and etiology of external impingement on symptomatic rotator cuff disease. Within the past decade, several randomized studies have demonstrated negligible benefits with acromioplasty performed alongside rotator cuff repair, with no significant differences in either patient-reported outcome scores or retear rates). Conversely, other authors have suggested higher rates of reoperation with rotator cuff repair alone. Critical shoulder angle, an objective measure of lateral acromion extension and glenoid inclination that is considered a gauge of external impingement, has demonstrated an association with rotator cuff tears; Despite this, patient-reported outcomes do not consistently correlate with critical shoulder angle or other variants in acromial morphology after arthroscopic full-thickness rotator cuff repair. Evidenced-based data is currently lacking to support routine use of acromioplasty in all cases of rotator cuff repair. However, the current available studies do present design flaws, namely statistical underpowering, particularly in type III acromion morphology; inadequate short-term follow-up; lack of imaging data to assess cuff healing; and insensitive outcome measures to capture the theorized benefits of subacromial decompression. Additionally, several relevant merits of acromioplasty have been reported, including decreased abrasive wear with prominent type III acromial morphology, release of natural growth factors to improve rotator cuff healing, and improved visualization during rotator cuff repair. Further evaluation is needed to determine the correct indications for acromioplasty in the setting of cuff repair. Current data would indicate that acromioplasty can be used safely at the discretion of the operating surgeon based on preoperative and intraoperative findings.     

Shoulder surgery for rotator cuff tears. Ultrasonographic 3-year follow-up of 97 cases

We reexamined 97 of 116 shoulders operated on for rotator cuff lesions after an average follow-up time of 37 months. Seventy percent had a good or excellent clinical result, and 14 percent were graded as poor. Upon ultrasonographic examination of the 97 shoulders, 37 had a normal rotator cuff, 31 had thinning and/or hyperdensity, and 29 had a complete rupture of the cuff. Patients with concomitant anterior acromioplasties did better than those without. There was a poor correlation between clinical and ultrasonographic results. We recommend that rotator cuff tears should be closed only if this can be achieved without undue tension. If extensive tissue mobilization or coverage with alloplastic material or with regional muscle flaps is required, the lesion should be debrided and left open, and only an anterior acromioplasty should be performed.     

Shoulder surgery for rotator cuff tears: Ultrasonographic 3-year follow-up of 97 cases

We reexamined 97 of 116 shoulders operated on for rotator cuff lesions after an average follow-up time of 37 months. Seventy percent had a good or excellent clinical result, and 14 percent were graded as poor. Upon ultrasonographic examination of the 97 shoulders, 37 had a normal rotator cuff, 31 had thinning and/or hyperdensity, and 29 had a complete rupture of the cuff. Patients with concomitant anterior acromioplasties did better than those without. There was a poor correlation between clinical and ultrasonographic results. We recommend that rotator cuff tears should be closed only if this can be achieved without undue tension. If extensive tissue mobilization or coverage with alloplastic material or with regional muscle flaps is required, the lesion should be debrided and left open, and only an anterior acromioplasty should be performed.     

Effect of Acromioplasty on Postoperative Pain Following Rotator Cuff Repair

Background: The surgical treatment of rotator cuff tears traditionally involves rotator cuff repair (RCR) with concomitant acromioplasty. However, there is some doubt as to whether acromioplasty is of value to this procedure. Questions/Purpose: We sought to evaluate whether RCR with acromioplasty provided better outcomes than RCR without acromioplasty in a cohort of more than 1000 patients. Methods: This retrospective cohort study involved 1320 patients with rotator cuff tears who subsequently received a primary arthroscopic RCR, with acromioplasty (n = 160) or without acromioplasty (n = 1160), performed by a single surgeon. Acromioplasty was performed if there was significant mechanical impingement on the rotator cuff. To assess outcomes, all patients completed a standardized, modified L’Insalata questionnaire in which they reported the level and severity of pain at rest and during activities. An examiner assessed shoulder strength and range of motion before and 1 week, 6 weeks, 12 weeks, and 6 months after surgery. Results: Patients who had RCR with concurrent acromioplasty had a greater level of pain and more frequent pain 1 week after surgery. However, at 6 months there were no differences between patients who underwent RCR with or without acromioplasty in any patient-reported outcome (level of pain with overhead activity, at rest and during sleep; frequency of pain with activity, sleep and extreme pain, difficulty of activity overhead and behind back, level of shoulder stiffness; and overall shoulder satisfaction). The postoperative re-tear rate in both groups was 13%. Conclusion: This study showed no additional benefit to acromioplasty in patients undergoing RCR.