Conflit sous-acromial : influence de la morphologie de la voûte acromiocoracoïdienne sur la valeur fonctionnelle de l'épaule

Subacromial impingement: influence of coracoacromial arch geometry on shoulder function. Objective. To look for correlations between radiological coracoacromial arch geometry and shoulder function in patients with subacromial impingement syndrome. Patients and methods. During a prospective study of the efficacy of arthroscopic subacromial decompression, we evaluated the function of the treated and contralateral shoulders using Constant's functional score and confronted the results to several radiographic parameters reflecting coracoacromial arch geometry. Results. Constant's score values were low (42±15) because of pain and a low level of activity. Males had significantly higher scores than females. Constant's score was unaffected (P>0.05) by patient age, the side, the level of activity, or the duration of symptoms, but was significantly influenced by the orientation of the acromion with respect to the scapular spine and to the vertical scapular axis. The preoperative Constant's score was significantly higher in patients with a more horizontal acromion (P=0.01). A very tight correlation was found between the preoperative Constant's score and the angle between the acromion and scapular spine (P=0.0003). Conclusion. Based on our results, we defined an open and a closed coracoacromial arch geometry. Coracoacromial arch geometry is correlated with shoulder function syndrome and can assist in the interpretation of rotator cuff impingement.     

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.     

Subacromial osteochondroma

The most common cause of impingement syndrome is mechanical irritation of the subacromial bursa and rotator cuff by the coracoacromial arch. Offending structures include the undersurface of the anterolateral acromion, coracoacromial ligament, and the undersurface of the distal clavicle. We present a case of impingement syndrome caused by mechanical irritation of the rotator cuff by a subacromial osteochondroma that was successfully treated with arthroscopic resection. Osteochondroma is the second most common benign bone tumor following nonossifying fibroma. These lesions are thought to arise from aberrant growth of normal epiphyseal growth plate cartilage. Ninety percent of osteochondromas arise from the metaphyseal regions of long bones (eg, distal femur, proximal tibia, or proximal humerus). Scapular involvement accounts for 3.0% to 4.6% of all reported osteochondromas. These lesions represent 14.4% of all tumors of the scapula and 49% of benign scapular tumors, making them the most common benign bone tumors of the scapula. Our patient failed nonoperative management of his subacromial osteochondroma. The concern for malignant transformation was low, as the patient's pain had been consistent for the past 15 years. Although his pain had been largely unchanged for more than a decade, he elected to undergo resection so that he could resume the hobbies that his pain had forced him to abandon. He reported substantial pain relief and restoration of function following arthroscopic resection and subacromial decompression, reinforcing mechanical irritation of the rotator cuff as the source of his shoulder pain and dysfunction. To our knowledge, this is the first report of arthroscopic resection of a subacromial osteochondroma.     

The relationship between clinical outcomes and the amount of arthroscopic acromial resection

Purpose: In 47 consecutive patients who had a shoulder impingement syndrome treated by arthroscopic subacromial decompression, we compared the functional outcome with the amount of the acromion resection. Type of Study: Prospective study. Methods: The inclusion criteria for patient selection was a chronic impingement syndrome unresolved by conservative treatment with an intact rotator cuff or with an irreparable rupture of the rotator cuff. The assessment was performed with the scoring system of Constant preoperatively and postoperatively. Quantitative measurements of the acromion resection were made by comparing preoperative and postoperative anteroposterior radiographic views, standardized under fluoroscopic control in order to become reproducible and comparable. There were 39 patients (41 shoulders) available for follow-up at 37 months. Results: The condition of the shoulder, concerning pain, motion and activities, was improved at the time of follow-up, the mean gain of the total functional score was 29 points/100. Age, side, activity, duration of pain before procedure and cuff statement had no influence on preoperative and postoperative Constant's score. The difference between preoperative and postoperative measurements of anterior acromion protuberance was significant. There was no correlation between the amount of the acromion resection and the improvement of Constant's score (P = .84). Conclusions: The origin of impingement syndrome is multi-factorial, and efficiency of arthroscopic decompression may not be only due to the amount of acromion resection. From these results and a literature review, this study analyzes several morphologic factors, which could explain the good results of arthroscopic subacromial decompression in impingement syndrome.     

Subacromial impingement decompressed with anterior acromioplasty

Symptomatic (Stage II) impingement of the rotator cuff against the coracoacromial arch has been treated with anterior acromioplasty in 60 shoulders in 56 patients. Patient selection is crucial. Arthrography of the shoulder was routinely included in the preoperative diagnostic tools to rule out a tear of the rotator cuff. Since acromial shape may play a role producing a resistant impingement syndrome, special attention should be paid to patients with Type III of acromial inclination. The surgical procedure should include a thorough examination of the subacromial space as a whole, taking notice of all pathologic findings in the subacromial arch as well as in the underlying soft tissues. Restoring subacromial clearance, the patients were relieved of their symptoms. The result, rated according to the functional assessment of Neer, was excellent or satisfactory in 73%. Failure to recognize the associated bony as well as soft-tissue subacromial lesions was, however, a frequent cause of failure of surgical decompression operations.     

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 role of acromion morphology in chronic subacromial impingement syndrome

This study investigated the role of acromion morphology in the aetiology of chronic subacromial impingement syndrome. Forty five patients with chronic subacromial impingement syndrome were included in the study. They were distributed into three groups according to their acromion types: six (13.3%) patients had type 1, 24 (533%) patients type 2 and 15 (333%) patients type 3 acromion. Constant scoring was used for clinical evaluation. Arthroscopic subacromial decompression was performed in all patients in the three groups, without performing any acromioplasty that would change the morphology of acromion. We then compared the average Constant scores changes in all three groups after arthroscopic subacromial decompression. The average follow-up was 28.6 months (range: 12-47). The average change in Constant score after arthroscopic subacromial decompression was 5830 in patients with type 1 acromion, 58.21 in those with type 2 and 54.07 in those with type 3. No significant difference was observed between the changes in the average Constant scores of the three groups (p > 0.005). The scores were significantly improved following arthroscopic subacromial decompression in all three groups (p < 0.005).In this study, acromion type was not found to have an important role in the aetiology of chronic impingement syndrome; arthroscopic subacromial decompression without simultaneous acromioplasty thus appears as an appropriate treatment.     

Acromial enthesopathy and rotator cuff tear. A radiologic and histologic postmortem investigation of the coracoacromial arch

Changes of the coracoacromial ligament (CAL) at its insertion into the undersurface of the acromion were studied radiologically and histologically in 76 autopsy specimens. Two changes were noted: (1) a downward, bony projection of the acromion, an anatomic variant limited to the area covered by the CAL, which might reduce the height of the subacromial compartment, and (2) a thickened layer of fibrocartilage, constituting a potential cause for narrowing of the subacromial space. The former might act as a predisposing factor for the impingement syndrome, whereas the latter could develop in response to pressure from constituents of the subacromial compartment. The acromial spur was a result of enchondral bone formation. A possible correlation between these changes and rotator cuff tears was investigated. The incidence and severity of cuff tears increased with age. However, there was no correlation between aging and degenerative changes of the undersurface of the acromion, except possibly in very advanced cases. Rotator cuff tears are unlikely to be initiated by impingement; rather, they develop as an intrinsic degenerative tendinopathy.     

Morphological study of mechanoreceptors on the coracoacromial ligament

We performed gold chloride staining of coracoacromial ligaments removed at operation, observed the peripheral nerve endings in the ligament, and studied their distribution and changes with aging in order to clarify the proprioception of the shoulder joint. The coracoacromial ligament was found to contain four types of typical nerve endings: Pacinian corpuscles, Ruffini receptors, Golgi tendon organ-like receptors, and free nerve endings. In addition, non-typical Pacinian corpuscles and Ruffini receptors with non-typical morphology were present. There were also unclassifiable nerve endings with a morphology which did not fit any of the above categories. These typical, non-typical, and unclassifiable nerve endings were all widely distributed on the surface of the subacromial side at the insertion into the acromion and around the coracoid process in the ligament. Free nerve endings were found sporadically on the surface of the subacromial bursal side in the ligament. The resected coracoacromial ligaments (23 specimens) were divided into two groups based on the disorder that required surgery: a fracture group without subacromial impingement (5 specimens) and a group with subacromial impingement (18 specimens). Age-related changes in the number of nerve endings were compared in each group. The total number of nerve endings decreased with age in both groups. The number of Pacinian corpuscles, Ruffini receptors, Golgi tendon organ-like receptors, and free nerve endings of typical morphology tended to decrease with age. The data from the fracture and subacromial impingement groups were not analyzed statistically because of the difference in the number of specimens in each group. However, the total number of nerve endings was lower in the subacromial impingement group than in the fracture group at all ages. The typical nerve endings of the coracoacromial ligament in both groups tended to decrease in the elderly, suggesting that the proprioception of the shoulder joint may become impaired with aging. Received for publication on June 16, 1997; accepted on Oct. 14, 1997     

Widening of the sub-acromial space using a wedge osteotomy of the scapular spine. Anatomical bases, measurements on the preparation, studies of the kinematics of the acromion movements on a computer model]

We describe the theoretical principles of a new kind of decompression of subacromial impingement syndrome by means of a wedge osteotomy at the transition between acromion and spine of the scapula. The operation on cadaver bone and the simulation of acromion movement in a computer model demonstrate an increase of subacromial space more than 1 cm after wedge excision with cranial base of 5 mm and ventral base of 3 mm. After the excision of an anterior based wedge the resection of the coracoacromial ligament is not necessary. An angle between 50 and 60 degrees from mediocranial to laterocaudal referred to the transverse plane has been calculated as optimal. We regard the sparing of the abducting parts of deltoid muscle, the better approach to the cuff with the possibility to mobilize the supraspinate muscle in cases of greater cuff-tears and the possibility to obtain a smooth undersurface of the acromion as further advantages of this procedure. Further biomechanic experiments will be necessary to optimize osteosynthesis.     

Tendon ruptures of the shoulder

Common sports, involving raising the arms above the head, i.e., throwing, racquet games and swimming, often result in rotator cuff tendinitis. During the throwing motion, the humeral head and its overlying biceps tendon and rotator cuff must pass rapidly under the coraco-acromial arch. Damage to these structures can occur by several mechanism. First, an increase in the size of the structures passing underneath the arch may lead to impingement. This can occur either by way of hypertrophy of the musculotendinous cuff or by way of inflammation of the cuff. Second, a decreased space available underneath the arch secondary to osteophyte formation of the acromion and fibrosis of the subacromial space may lead to impingement. Third, weakness or incompetence of the rotator cuff allows the humerus to ride up and impinge on the coracoacromial arch with motion of the shoulder. Tendinitis can be combined with increased laxity of the glenohumeral joint and/or acquired instability due to a labral tear. Prevention of overuse injuries is a cornerstone of our treatment concept. The muscle tendon unit requires passive and neuromuscular facilitated streching after warming-up exercises. Muscular imbalance and weakness are prevented by balanced eccentric strenthening with particular attention to the external rotators and scapular muscles. Knowledge of the mechanics of the pitching motion, tennis serve, swimming stroke, etc. is of paramount importance in the prevention of injuries. As the onset of shoulder problems contributes to a particularly fatiguing situation, extreme fatique performance severity should be avoided. Every effort must be made to apply conservative treatment when overuse problems arise in the athlete's shoulder.(ABSTRACT TRUNCATED AT 250 WORDS)     

Adhesion of the subacromial bursa may cause subacromial impingement in patients with rotator cuff tears: pressure measurements in 18 patients

In order to determine whether adhesion of the subacromial bursa leads to impingement, we measured the subacromial contact pressures before and after release of adhesion of this bursa. 18 shoulders with cuff tears and adhesion of the subacromial bursa were evaluated in 8 male and 10 female patients, of mean age 62 (53-71) years and who had no particular limitation of shoulder motion. We recorded subacromial pressures using a very sensitive film inserted under the acromion during surgery. In passive scapular plane elevation (scaption) at 100 degrees, the mean subacromial contact pressure and area declined from 1.43 (SD 0.23) MPa before release to 1.14 (SD 0.35) MPa after release (p < 0.001), and from 163 (SD 81) mm2 before release to 80 (SD 46) mm2 after release (p < 0.001), respectively. We suggest that adhesion of the subacromial bursa increases impingement between the acromion and the insertion of rotator cuff tendons.     

Coracoacromial ligament release for shoulder impingement syndrome using the Universal Subcutaneous Endoscope system.

We developed a new operative procedure of coracoacromial ligament release for shoulder impingement syndrome. The operative procedure was confirmed by cadaveric studies and applied to clinical cases in 40 shoulders of 37 patients who suffered from shoulder impingement without bony abnormalities. The subacromial space was observed under local anesthesia using the Universal Subcutaneous Endoscope (USE) system on an outpatient basis. A popping phenomenon was observed between the coracoacromial ligament and the greater tuberosity of the humerus, which was covered by the rotator cuff, and the coracoacromial ligament was resected with a rongeur under endoscopic visualization in all shoulders. Resection of the coracoacromial ligament relieved the impingement and clinical signs, as in open or arthroscopic resection of the coracoacromial ligament. Resection of the coracoacromial ligament using the USE system is a safe and less-stressful surgical invasion than open or standard arthroscopic resection of the coracoacromial ligament.     

Pseudo-arthrosis of the spine of the scapula: a case report with a delayed diagnosis

Scapular spine fractures are rare injuries. The aim of this study was to evaluate a late-diagnosed scapular spine pseudo-arthrotic patient. Because of the surrounding soft tissue mass and overlapping of the scapula with the thoracal bones on a roentgenogram, diagnosis may be missed or delayed for years. We present a case of scapular spine pseudo-arthrosis in a 50-year-old man, who sustained a traffic accident 2 years ago. He was treated as a soft tissue injury of the left shoulder and later as a rotator cuff tear. His scapular spine fracture was diagnosed as pseudo-arthrosis of the scapular spine with a diagnostic delay of 2 years. Isolated scapular spine fractures are rare, usually associated with other injuries and frequently treated non-operatively. Sagging of the acromion as a result of a scapular spine fracture may mimic supraspinatus outlet impingement. If a painful pseudo-arthrosis limits the function of a shoulder, fractured ends should be fixed until union occurs. Although scapular spine fractures are rarely seen, they must take place in the differential diagnosis of impingement syndromes of the shoulder.     

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.     

Subacromial impingement syndrome: the effect of changing posture on shoulder range of movement

STUDY DESIGN: Random allocation of subjects into a placebo-controlled, crossover study. OBJECTIVES: To investigate the effect of changing thoracic and scapular posture on shoulder flexion and scapular plane abduction range of motion in asymptomatic subjects, and in subjects with subacromial impingement syndrome. BACKGROUND: Changes in upper body posture and concomitant imbalance of the muscle system have been proposed as one of the etiological mechanisms leading to subacromial impingement syndrome. Although clinicians commonly assess posture and devise rehabilitation programs to correct posture, there is little evidence to support this practice. METHODS AND MATERIALS: Selected postural, range of movement, and pain measurements were investigated in 60 asymptomatic subjects and 60 subjects with subacromial impingement syndrome, prior to and following thoracic and scapular taping intended to change their posture. RESULTS: Changing posture had an effect on all components of posture measured (P<.001) and these changes were associated with a significant increase (P<.001) in the range of motion in shoulder flexion and abduction in the plane of the scapula. Changing posture was not found to have a significant effect on the intensity of pain experienced by the symptomatic subjects, although the point in the range of shoulder elevation at which they experienced their pain was significantly higher (P<.001). CONCLUSIONS: The findings of this investigation suggest that changing 1 or more of the components of posture may have a positive effect on shoulder range of movement and the point at which pain is experienced.     

3-dimensional image analysis of the shoulder joint--a new method for characterizing parameters of shoulder joint function

OBJECTIVE: An exact assessment of shoulder movement is of special importance both in the diagnosis of and in the therapy for different shoulder diseases. Therefore, we developed a feasible method for the analysis of shoulder movement. METHODS: On the basis of an ELITE system and 6 skin markers (marker positions. acromion, humerus, olecranon, proc. styloideus ulnae, cervical and thoracic spine), movement analysis was performed during continuous abduction of the arm over 15 s. With the help of a purpose made software we determined the exact angle of abduction and, in addition, the acceleration (+aAC) and the deceleration (-aAC) of the acromion. We evaluated 12 normal subjects (10 male, 2 female, average age 29 yrs) without shoulder conditions and 8 patients (6 male, 2 female, average age 46 yrs.) with unilateral impingement syndrome stage II according to Neer. RESULTS: In addition to a significantly diminished abduction ability in patients with impingement syndrome, our results also revealed significantly decreased acceleration values for the acromion in impingement patients. In contrast, deceleration values for the acromion were not altered in patients with impingement syndrome. CONCLUSION: The presented method allows exact measurements of shoulder movement. In addition, measurements of acromion acceleration and deceleration seem to offer two parameters for the assessment of shoulder function in pathological conditions. Further investigations are required to prove the advantages and limitations of this method.     

Adhesion of the subacromial bursa may cause subacromial impingement in patients with rotator cuff tearsPressure measurements in 18 patients

In order to determine whether adhesion of the subacromial bursa leads to impingement, we measured the subacromial contact pressures before and after release of adhesion of this bursa. 18 shoulders with cuff tears and adhesion of the subacromial bursa were evaluated in 8 male and 10 female patients, of mean age 62 (53–71) years and who had no particular limitation of shoulder motion. We recorded subacromial pressures using a very sensitive film inserted under the acromion during surgery. In passive scapular plane elevation (scaption) at 100°, the mean subacromial contact pressure and area declined from 1.43?(SD 0.23)?MPa before release to 1.14?(SD 0.35)?MPa after release (p?2before release to 80?(SD 46)?mm²after release (p?相似文献   

针刀松解术治疗肩峰下撞击综合征的临床疗效

目的:观察针刀松解术治疗肩峰下撞击综合征的临床疗效。方法:病例来源于2013年9月至2014年8月的肩峰下撞击综合征患者,共90例。其中女61例,男29例;年龄45~65(55.21±8.30)岁;病程1~7(3.49±2.98)个月;左肩26例,右肩64例。局麻下,采用针刀松解肩峰下缘痛点及肩峰下滑囊粘连。通过观察肩关节外展、前屈上举、屈肘内旋、屈肘外旋的活动度,肩关节疼痛评分,统计治疗后治愈、显效、有效、无效的病例数,对针刀治疗肩峰下撞击综合征的疗效进行评价。结果:所有患者顺利完成治疗,无明显不良反应。所有患者完成12个月以上随访,无失访病例。随访VAS疼痛评分1.35±0.78,较术前7.72±5.42减小(t=15.89,P0.01)。术后12个月Constant评分83.17±19.11,较术前58.89±15.63提高(t=28.48,P0.01)。总体疗效评价,治愈46例,显效33例,有效11例,无效0例。结论:针刀治疗肩峰下撞击征的优点是微创地解决根本病变,缺点是不能处理骨质异常引起的撞击。