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.     

Regeneration of the coracoacromial ligament after acromioplasty and arthroscopic subacromial decompression

The clinical observation of apparent and complete regeneration of the coracoacromial ligament after known partial excision of the ligament and acromioplasty has been investigated. Ten patients who had open revision surgery following failure of symptomatic relief after arthroscopic subacromial decompression were studied. All of them had acromioplasty with documented partial resection of the coracoacromial ligament at the first operation. There were 5 men and 5 women with an average age of 54.5 years (range, 44-65 years). In all patients surgery revealed a ligamentous structure resembling the coracoacromial ligament that was attached to the anterior acromion. Histology in all patients revealed appearances indistinguishable from normal ligament, which was in continuity with the reformed periosteum of the acromion.     

The CARE technique: arthroscopic CoracoAcromial ligament RE-attachment

During standard acromioplasty, the inferior fibers of the coracoacromial ligament are inevitably detached. Partial or complete sectioning of the coracoacromial ligament results in secondary weakening of the deltoid muscle and an incremental risk of anterior–superior glenohumeral migration. This technique allows the re-attachment of the inferior fibers to the intact portion of the ligament and re-establishes mechanical continuity of the coracohumeral arc.     

Improvement in comfort and function after cuff repair without acromioplasty

The repair of full thickness rotator cuff tears traditionally has included acromioplasty and coracoacromial ligament section. Acromioplasty can be complicated by deltoid detachment, compromise of the deltoid lever arm, anterosuperior instability, and adhesions of the rotator cuff tendons under the bleeding cancellous bone of the osteotomized acromion. This report concerns the improvement in shoulder function at a minimum of 2 years after 27 full thickness rotator cuff repairs were done without deltoid detachment, acromioplasty, or section of the coracoacromial ligament. The mean number of Simple Shoulder Test functions that the patients could do increased from six of 12 before surgery to 10 of 12 at an average followup of 4 years after surgery. Eight of 12 individual Simple Shoulder Test functions were significantly improved after the procedure. There also was a significant improvement in the Short Form-36 comfort, physical role function, and mental health scores. When done without acromioplasty, cuff repair avoids the possibility of deltoid detachment, altered deltoid mechanics, anterosuperior instability, and tendon scarring to the cancellous undersurface of the acromion.     

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.     

A technique for arthroscopic subacromial decompression.

The control of bleeding and the determination of the appropriate amount of bone to resect are two common technical difficulties in performing arthroscopic subacromial decompression. We describe a technique that simplifies the procedure while providing more precise bone resection and contouring. First, the coracoacromial ligament is released by sectioning the anterior margin of the acromion. Bleeding is minimized with this technique because the coracoacromial ligament itself is not being cut, but rather its bony attachment is resected. An acromioplasty is then performed with the arthroscope in the lateral portal and the burr in the posterior portal. The shank of the cutter is rested against the posterior lip of the acromion, which acts as a fulcrum. The tip of the burr is placed at the deepest point of the concavity of the acromion. Bone is resected by sweeping the cutter from lateral to medial and progressing anteriorly while maintaining the angle of the burr, using the angle of the posterior acromion as a guide. In this way the appropriate amount of bone is automatically resected, resulting in a flat acromion which is tapered anteriorly and has a smooth transition to normal bone posteriorly.     

不同类型肩峰下骨赘对肩袖肌腱病关节镜治疗的影响

目的观察肩峰外侧骨赘对关节镜下肩峰成形术治疗肩袖肌腱病临床疗效的影响。 方法对2016年1月至2016年12月在中山大学孙逸仙纪念医院行肩峰成形术的68例肩袖肌腱病患者进行回顾性研究。依据患者肩关节X线检查将其肩峰下骨赘分为外侧型骨赘和前侧型骨赘两大类。采用视觉模拟评分法（visual analogue scale/score,VAS）、Constant肩关节评分、12条生存质量量表（12-items the short form health survey questionnaire, SF-12）评分进行术前及术后3个月评分。 结果68例患者中26例为外侧型,42例为前侧型。术前外侧型患者的VAS、Constant、SF-12评分明显劣于前侧型患者（P<0.05）。术后3个月,外侧型患者VAS评分降低（3.64 ± 0.54）分,前侧型患者VAS评分降低（2.61±0.09）分,外侧型患者VAS评分改善显著（P<0.05）。其Constant、SF-12评分改善也更为明显（P<0.05）。 结论肩峰下骨赘的形态短期内影响肩袖肌腱病的临床效果。外侧型骨赘的患者临床症状更严重,但手术效果改善也较为明显。     

Histological analysis of the coracoacromial arch: Correlation between age-related changes and rotator cuff tears

The purpose of this study was to analyze age-related changes in the coracoacromial arch and correlate these degenerative changes with rotator cuff tears. We obtained 80 shouldes from 40 cadavers. The mean age at death was 58.4 years. We performed a gross examination of the rotator cuff and the acromion and histological examination of the coracoacromial ligament. The statistical significance of any difference for each group considered was determined by Student's t-test. The rotator cuff was normal in 66 specimens; there was an articular-side partial tear in 4 cases, a bursal-side partial tear in 6 cases, and a full-thickness tear in 4 cases. Age was correlated with increasing incidence and severity of cuff tears. We noted age-related degenerative changes in the coracoacromial ligament, degeneration of the acromial bone-ligament junction, and acromial spur formation. Anterior acromial spur was not related to the morphology of the acromion. We observed an increased incidence of bursal-side and complete cuff tears when the acromion was curved or beaked. Degenerative changes in the undersurface of the acromion were also present when the rotator cuff was normal. Bursal-side and complete cuff tears were associated with severe degenerative changes in the acromion in 100% of cases. Articular-side cuff tears were not related either to acromial morphology or degenerative changes in the coracoacromial arch. The association between cuff tears and acromial spur was more evident in the presence of a type III acromion. Our results would suggest that the incidence and severity of rotator cuff tears are correlated with aging and with the morphology of the acromion. Rotator cuff tears that involve the bursal side are often associated with changes in the coracoacromial ligament and the undersurface of the acromion. However, degenerative changes in the coracoacromial arch are always related to aging, also in the presence of a normal rotator cuff. Articular-side partial tears do not cause damage to the undersurface of the acromion.     

Editorial Commentary: Acromioplasty Does Not Improve Clinical Outcome of Arthroscopic Rotator Cuff Repair: The Game Is Over!

Acromioplasty is a well-known, simple, and reproducible surgical technique that is used in isolation or in combination with other arthroscopic procedures. The clinical value of acromioplasty combined with arthroscopic rotator cuff repair has been largely investigated. Main theoretical benefits lie in the opportunity to improve the visualization, decrease abrasive wear with prominent acromial morphology, and release natural growth factors. On the other hand, acromioplasty and release of the coracoacromial ligament may weaken the insertion of the deltoid muscle, induce scar formation in the subacromial space, theoretically limiting shoulder mobility, and increase risk of anterior-superior humeral escape, especially in patients with large to massive rotator cuff tears. Clinical studies report conflicting results. My results show no differences in clinical outcomes in rotator cuff repairs with or without subacromial decompression, regardless of the acromial morphology. At the same time, I do believe that confirmatory studies are always necessary, especially if the aim is to disprove the usefulness of a common practice.     

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.     

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.     

The value of acromioplasty in the treatment of subacromial impingement syndrome

Although acromioplasty is widely used in the treatment of subacromial impingement syndrome, there is some controversy about the role of acromion morphology in the etiology. The acromion and the coracoacromial ligament provide passive stabilization against upward migration of the humeral head and play an important role in shoulder biomechanics. This article discusses relevant issues on subacromial impingement syndrome pertaining to the acromion and the value of acromioplasty in the treatment.     

Precision acromioplasty in arthroscopic subacromial decompression of the shoulder.

Arthroscopic techniques for subacromial decompression have been criticized for lack of precision in resecting the anterior acromial undersurface and evaluating the amount of bone resected. The goal of subacromial decompression is production of a flat undersurface for the acromion and acromioclavicular joint, thus enlarging the supraspinatus outlet and deterring impingement. Achieving this goal using the arthroscope requires preoperative evaluation of the acromial morphology, planning of the dimensions of bony resection, a reproducible acromioplasty method with intraoperative evaluation of the adequacy of resection, and postoperative confirmation of the resulting acromial shape. A precise technique for arthroscopic acromioplasty has been developed in the course of performing over 200 shoulder arthroscopies. This method adheres to conventional open surgical goals for bony resection and allows for reliable intraoperative evaluation of the result. Using this technique, over 90% good and excellent results may be achieved in treatment of stage II subacromial impingement syndrome.     

三维测量分析肩峰前缘骨赘对肩峰形态的影响

目的通过三维测量接受肩关节镜手术患者术前、术后肩峰前缘骨赘及肩峰形态，分析肩峰前缘骨赘在不同肩峰类型及肩袖损伤程度组间的差异，探讨肩峰前缘骨赘变化与年龄、肩峰形态及肩关节疾病的关系。 方法选取上海交通大学医学院附属第九人民医院2016年10月至2018年5月进行肩关节镜手术患者129例。所有患者在关节镜下行肩峰成形术，手术前、后常规拍摄标准肩关节前后位、标准冈上肌出口位X线片及肩关节CT薄层平扫，经三维重建后在肩关节三维模型上测量手术前、后肩峰前缘骨赘距离（acromial spur distance，ASD）、肩峰倾斜角（acromial slope angle，ASA）及肩峰弧高度（acromial curvature height，ACH）。 结果术前ASD平均为（4.14±1.89） mm，ASA平均为24.73°±2.19°，ACH平均为（3.71±0.48） mm。研究对象年龄平均为（61.03±7.15）岁。Ⅰ型、Ⅱ型、Ⅲ型肩峰组间的年龄逐渐增大，呈显著正相关。ASD与年龄存在显著的正相关关系，P=0.014。ASD在Ⅲ型肩峰组及肩袖完全损伤组较其他组显著增大，差异有统计学意义。不同肩峰类型及肩袖损伤程度组间ASA及ACH没有差异。肩关节镜术后ASD显著减小，P<0.001。Ⅰ型和Ⅱ型肩峰组手术前、后ASA及ACH没有差异，而在Ⅲ型肩峰组则表现出显著的差异，P值分别为0.012及0.038。术后6个月Constant肩关节功能评分平均为（92.21±4.11）分，美国加州大学肩关节功能评分平均为（30.96±2.54）分，与术后ASD变化无相关性（P=0.427）。 结论数字化三维建立模型评估肩峰形态能提高测量的精度和广度。年龄仍然是预测肩峰形态及前缘骨赘的一个重要指标。ASD增大在Ⅲ型钩状肩峰中发生率较高并能改变肩峰原有形态，造成肩峰ASA及ACH增大，引起肩峰撞击及肩袖损伤风险增大。在Ⅲ型肩峰患者镜下手术时应常规行肩峰成形术并特别注意肩峰前缘骨赘的位置以确保恢复肩峰正常形态，而对于Ⅰ型及Ⅱ型肩峰患者镜下应酌情选择行肩峰成形术。     

The anterolateral intertubercular approach to the shoulder with osteotomy of the lesser tubercle of the humerus

Summary The authors propose an original route of approach to the shoulder that allows direct access to this articulation. Thanks to this route, complex fractures of the proximal end of the humerus can be treated by ostosynthesis or prosthesis, and shoulder arthroses, whether centered or not by prosthesis. Two technical methods are used: first, the creation of an anterior digastric trapezio-deltoid muscle flap, and then, in cases of elective prosthetic surgery, osteotomy of the lesser tubercle to open the articulation and provide direct access to the humeral head and the glenoid. The patient is installed in the semiseated position, with the apex of the shoulder projecting widely from the operating table. The incision is anterolateral, in the direction of the fibers of the deltoid and measures 8–10 cm from the anterolateral angle of the acromion (ALAA), which constitutes a convenient surgical landmark. One third of the incision is proximal; the other two-thirds are distal. The trapezio-deltoid digastric muscle flap is created: the deltoid is divided in the direction of its fibers between the anterior and middle bundles, straddling the ALAA. The acromial periosteum is incised vertically. The incision is extended upwards into the trapezius. The digastric muscle flap thus created is reflected forward together with the coracoacromial ligament. An acromioplasty can be performed. This approach by itself allows access to the upper end of the humerus in complex fractures and allows osteosynthesis if called for. In cases of elective prosthetic surgery, and if the rotator cuff is intact, complete access to the articulation is obtained by osteotomy of the lesser tubercle in a plane parallel to its humeral base. This allows reflection of the subscapularis muscle with the tubercular fragment and opening of the articulation. Retropulsion of the elbow and lateral rotation displays the humeral head, which is osteotomized, and in this way access to the glenoid is immediate. The different stages of prosthetic surgery can then be performed. Closure is made most simply by reattachment of the lesser tubercle with a stout transosseous suture. The trapezio-deltoid digastric flap is closed by interrupted sutures without tension.      

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.     

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 influence of variations of the coracoacromial arch on the development of rotator cuff tears

In order to define the geometry of the coracoacromial arch in both its bony and soft parts and to bring it into relationship with rotator cuff tears, 54 cadaver shoulders (from subjects aged 47–90 years) were dissected And X-rayed (anteroposterior projection and supraspinatus outlet view). Partial rotator cuff tears were assessed additionally by transillumination and polarized microscopy. After transfixation of the coracoacromial arch with a polyurethane mould, sections were made along the coracoacromial ligament. The morphology of the acromion was described following the classification of Bigliani et al. [5]. Amongst other parameters, measurements were taken between the long axis of the scapula, the spina, and the acromion. In 19 of 22 cases, a traction osteophyte was associated with rotator cuff tears. In incomplete tears, spurs were completely encased within the ligament and did not impair the subacromial space. The number of rotator cuff tears was significantly increased in shoulders with curved acromia, flat acromial slope, and increased angle between the scapular plane and the spina (intact, mean 58°; tears, mean 47°). The morphology of the subacromial space was secondarily determined by this angle. In contrast to Bigliani et al. we were unable to find a hooked acromion. These results indicate that the combination of a flat and curved acromion or a position of the acromioclavicular joint above the cranial pole of the glenoid must be regarded as considerable risks for the development of rotator cuff tears. The concept of anterior acromioplasty is supported by our results.     

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.     

The measurement of subacromial contact pressure in patients with impingement syndrome.

This study presents the subacromial contact pressure findings in 25 patients who underwent an arthroscopic acromioplasty for impingement syndrome. All patients failed a course of conservative management before surgery. Patients were evaluated, both before and after acromioplasty, by examination, UCLA functional score, and radiographic assessment of acromial morphology. At the time of surgery, a 4 x 10 mm air-filled catheter was placed beneath the anterior aspect of the acromion under arthroscopic visualization. Subacromial contact pressures were recorded throughout an arc of shoulder motion. Mean pressure and standard deviation were derived from three trials. This protocol was performed on all patients and the results were statistically evaluated. The mean subacromial pressure before acromioplasty was 11.7, 35.6, 50.1, 51.1, and 57.4 mm Hg at abduction arcs of 0 degrees , 90 degrees , and 180 degrees, hyperabduction (forced passive limit of abduction), and cross-reach (arm adducted across the patient's chest with the shoulder internally rotated), respectively. The pressure after acromioplasty decreased to 1.6, 7.8, 15.9, 22.8, and 16.5 mm Hg, respectively. This decrease was significant in all positions (P = .016 at 0 degrees and <.001 in all other positions). At 90 degrees of abduction, pressure always decreased in internal rotation and increased in external rotation. Maximal contact pressure developed in either hyperabduction or cross-reach in all patients except two. Preoperative testing for the position of maximum impingement pain generally correlated with the position of maximum contact pressure.