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Arthroscopic Rotator Cuff Disease Management: Current Role of the Acromioplasty

Omar Faour Martín, Jose Antonio Valverde García, Aurelio Vega Castrillo, Miguel Ángel Martín Ferrero, Patricia Zuil Acosta, Javier Alarcón García, María Angeles de la Red gallego

Omar Faour Martín, Javier Alarcón García, Service of Traumatology and Orthopaedic Surgery, Hospital of Ávila, Spain
Jose Antonio Valverde García, Chairman Service of Traumatology and Orthopaedic Surgery, Hospital of Ávila, Spain
Aurelio Vega Castrillo, Miguel Ángel Martín Ferrero, Service of Traumatology and Orthopaedic Surgery, Clinic Universitary Hospital of Valladolid, Spain
Patricia Zuil Acosta, Department of Orthopaedics , Hospital Severo-Ochoa, Leganés, Spain María Angeles de la Red gallego, Service of Traumatology and Orthopaedic Surgery, Santander, Spain

Correspondence to: Omar Faour Martín, Service of Traumatology and Orthopaedic Surgery, Hospital of Ávila, C\ Antonio Montesinos, Nº 2, 1º C, 37003, Salamanca, Spain
Email: ofmartin@msn.com
Telephone: +34- 630081151
Received: October 10, 2014
Revised: November 7, 2014
Accepted: November 12, 2014
Published online: January 23, 2015

ABSTRACT

Acromioplasty is a well-described surgical step used for a variety of rotator cuff pathologies. Although its incidence has increased greatly in last years, its role in rotator cuff surgery has been debated. In this review the recent evidence available at this respect is exposed. There is increasing number of published reports examining the role of acromioplasty in the treatment of rotator cuff disease. Evidence does not support the routine use of acromioplasty in the treatment of the impignement syndrome and rotator cuff repairs, on the basis of multiple well-designed studies suggesting acromioplasty providing no benefits in terms of pain relief, function or quality of life.

© 2015 The Authors. Published by ACT Publishing Group Ltd.

Key Words: Shoulder; Arthroscopic; Rotator; Treatment; Acromioplasty

Faour Martín O, Valverde García JA, Vega Castrillo A, Martín Ferrero MÁ, Zuil Acosta P, Alarcón García J, de la Red gallego MA. Arthroscopic Rotator Cuff Disease Management: Current Role of the Acromioplasty. International Journal of Orthopaedics 2015; 2(2): 227-231 Available from: URL: http://www.ghrnet.org/index.php/ijo/article/view/1145

Introduction

Subacromial decompression has been advocated as an integral part of rotator cuff repair as well as an effective treatment with respect to pain relief and shoulder motion improvement[1]. However, the efficacy of subacromial decompression, specifically acromioplasty, is still under debate even though it has been routinely performed during supraspinatus tendon repair[2].

The frequency of anterior acromioplasty has dramatically raised over time[3]. Increasing knowledge about shoulder pathogenesis, including better imaging, has facilitated patient treatment for a stable spectrum of rotator cuff pathology as has the application of endoscopic surgery[4]. Among these diseases are included subacromial bursitis, rotator cuff tendinosis, and partial thickness and full-thickness rotator cuff tears.

Since the original description of Neer[5] various technical modifications have been proposed for the anterior acromioplasty. Ellman et al[6] described an arthroscopic technique to perform a resection of the anterior acromion undersurface, coracoacromial ligament release and bursal debridement. Others authors[7] have indicated the need of avoiding resection or release of the coracoacromial ligament in order to avoid the potential complication consisting in the avulsion of the deltoid origin due to its weakening by the procedure.

Supporters and detractors of acromioplasty during rotator cuff procedures have based their surgical practice on different theoretic pathogenesis models. The rationale for acromioplasty is based on the extrinsic impingement theory of Neer, which describes irritation of the rotator cuff under the coracoacromial arch[8]. According to this hypothesis the acromial morphology is the initiating factor leading to dysfunction of the rotator cuff and eventual tearing. The influence of this theory on the practice of shoulder surgery has been profound[9-12].

In contrast, bursectomy alone without acromioplasty may be considered adequate by those who subscribe to the intrinsic theory[13], since symptoms are felt to be caused by degenerative tendinopathy and subsequent inflammation of the bursa with observed changes in the acromion felt to be secondary. Due to this intratendinous degeneration or tendinosis an eccentric tensile overload would occur at a rate greater than the ability of the cuff to repair itself. Therefore acromioplasty would fail to address the aforementioned primary problem of intratendinous degeneration. Additional investigations showed that the development of the acromial bony spur is a secondary degenerative change, implying that the majority of rotator cuff tears are initiated not by impingement but by an intrinsic degenerative tendinopathy[13,14].

The objective of this review article is to summarize and review the current evidence in relation to the role of acromioplasty both for subacromial impingement syndrome and during arthroscopic repair of rotator cuff tears.

Impignement syndrome

In subacromial impingement there is a disruption of the normal sliding mechanism, while lifting the arm, by compression of the tissues between the coracoacromial arch and the greater humeral tuberosity.

Rotator cuff disease with subacromial impingement has been described in 3 stages[14]: stage 1, acute inflammation and either tendonitis or bursitis; stage 2, chronic inflammation with or without degeneration; and stage 3, rupture of the cuff.

Ketola et al[15] reported a randomised controlled trial with the examination of the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n=70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n=70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available. An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p=0.65). The combined treatment was considerably more costly. Arthroscopic acromioplasty provided no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Authors concluded that structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven.

Henkus et al[16] published a randomized controlled trial focusing on the treatment of impingement syndrome without rotator cuff tears. Fifty-seven patients were randomized either into arthroscopic bursectomy (26 patients) or bursectomy with acromioplasty groups (30 patients); one patient was lost to follow up. At a mean followup of 2.5 years (range, 1-5 years), both bursectomy and acromioplasty groups had good clinical outcomes, and there were no significant differences between the groups. Acromial morphology affected the outcome of both groups, but when stratified based on acromial morphology, the two groups again were no different in outcome.

Haahr and colleagues[17] performed a randomized control study with 1-year follow-up comparing exercise to subacromial arthroscopic decompresion. They found no statistically significant difference in the mean change in Constant scores between groups at 3, 6, and 12 months or in the Project on Research and Intervention in Monotonous Work scores (aggregated pain and dysfunction score) at 12 months. However we consider that these findings need to be considered with caution because usually surgery is only indicated if conservative treatment fails. If surgery is used as primary treatment for impingement maybe a lot of these patients would have improved with physiotherapy.

Rotator cuff repair

Acromioplasty is commonly performed during arthroscopic rotator cuff repair, but its effect on outcomes is debated. Several studies have tried to determine the efficacy of subacromial decompression in the arthroscopic treatment of full-thickness rotator cuff tears. In order to assess the role of acromioplasty in the arthroscopic repair of small- to medium-sized rotator cuff tears Shin et al[18] performed a prospective randomized trial of 120 patients who had small- to medium-sized rotator cuff tears and various types of acromions without spurs were included. Sixty patients received arthroscopic rotator cuff repair with acromioplasty (group I), and another sixty received the same procedure without acromioplasty (groupII). The mean tear size was similar in the two groups. Clinical outcome at a mean of 35 months after surgery was significantly improved in both groups after arthroscopic rotator cuff repair. There were no significant differences with respect to pain and range of motion between the groups at the final follow-up. Functional outcomes also showed no significant differences between the 2 groups (American Shoulder and Elbow Surgeons scoreb and University of California, Los Angeles score). Postoperative imaging showed that the retear rate was 17% in group I and 20% in group II. Authors considered that arthroscopic repair of small- to medium-sized rotator cuff tears provided pain relief and improved functional outcome with or without acromioplasty and that clinical outcomes were not significantly different, and acromioplasty may not be necessary in the operative treatment of patients with small- to medium-sized rotator cuff tears in the absence of acromial spurs.

McDonald et al[19] performed a prospective randomized controlled trial to compare functional and quality of-life index and rates of revision surgery in arthroscopic rotator cuff repair with and without acromioplasty. The primary outcome was the Western Ontario Rotator Cuff (WORC) index. Secondary outcome measures included the American Shoulder and Elbow Surgeons (ASES) shoulder assessment form and a count of revisions required in each group. Outcome measures were completed preoperatively and at three, six, twelve, eighteen, and twenty-four months after surgery. There were no differences in WORC or ASES scores between the groups that had arthroscopic cuff repair with or without acromioplasty at any time point. There were no differences in scores on the basis of acromion type, nor were any interaction effects identified between group and acromion type. Four participants (9%) in the group that had arthroscopic cuff repair alone, one with a Type-2 and three with a Type-3 acromion, required additional surgery by the twenty-four-month time point. The number of patients who required additional surgery was greater (p=0.05) in the group that had arthroscopic cuff repair alone than in the group that had arthroscopic cuff repair and acromioplasty. Authors concluded that there was no difference in functional and quality-of-life indices for patients who had rotator cuff repair with or with out acromioplasty however a higher reoperation rate was found in the group without acromioplasty.

In another randomized controlled trial, Abrams et al[20] reported the clinical outcomes of patients undergoing arthroscopic repair of full-thickness rotator cuff tears with and without acromioplasty. Authors conclude that there were no significant differences in functional outcomes between nonacromioplasty and acromioplasty groups or between subjects with different acromial features at any time point. The results of this study demonstrated no difference in clinical results after rotator cuff repair with or without acromioplasty at 2 years postoperatively.

In a systematic review[21] authors included the evaluation of partial articular-sided rotator cuff tears treated with debridement. Tear grade and depth were not recorded. Mean follow-up was 23 months. Twenty-six patients (84%) had satisfactory outcomes (UCLA score greater than 28). Results were similar in patients who had a subacromial decompression compared to those without.

In a recent study, Lee et al[22], concluded that arthroscopic tuberoplasty with concomitant acromioplasty would be an option for diminishing pain and improving active forward elevation for irreparable massive rotator cuff tears. In particular, satisfactory results during the minimum follow-up period of 24 months can be achieved in the cases with good preservation of the preoperative and postoperative acromiohumeral interval and continuity in the inferior scapulohumeral line, regardless of preoperative mobility.

In relation to reoperation rates after rotator cuff repair of full thickness tears with and without acromioplasty, a systematic review that included three prospective randomized controlled trials[23], revealed no significant differences between groups of the reoperation rate in the first 2 years after surgery. However, due to the strong trend found at this respect by MacDonald and colleagues[19] in the number of patients who required reoperation in the non-acromioplasty group we consider that long-term follow-up studies are needed to determine whether differences exist in retear and reoperation rates between groups.

Conclusions

There is increasing number of published reports examining the role of acromioplasty in the treatment of rotator cuff disease (Table 1). Evidence does not support the routine use of acromioplasty in the treatment of rotator cuff disease, mainly in relation to tears management, on the basis of multiple well-designed studies suggesting acromioplasty providing no added benefits in terms of pain relief, better function or improving quality of life.

CONFLICT OF INTEREST

There are no conflicts of interest with regard to the present study.

REFERENCES

1 Vitale MA, Arons RR, Hurwitz S, Ahmad CS, Levine WN. The rising incidence of acromioplasty. J Bone Joint Surg Am 2010; 92: 1842-1850

2 Milano G, Grasso A, Salvatore M, Zarelli D, Deriu L, Fabbriciani C. Arthroscopic rotator cuff repair with and without subacromial decompression: A prospective randomized study. Arthroscopy 2007; 23: 81-88

3 Yu E, Cil A, Harmsen WS, Schleck C, Sperling JW, Cofield RH. Arthroscopy and the dramatic increase in frequency of anterior acromioplasty from 1980 to 2005: an epidemiologic study. Arthroscopy 2010; 26(Suppl 9): S142

4 Oh JH, Kim JY, Choi JA, Kim WS. Effectiveness of multidetector computed tomography arthrography for the diagnosis of shoulder pathology: Comparison with magnetic resonance imaging with arthroscopic correlation. J Shoulder Elbow Surg 2010; 19: 14-20

5 Neer CS II. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am 1972; 54: 41-50

6 Ellman H. Arthroscopic subacromial decompression: analysis of one- to three-year results. Arthroscopy 1987; 3(3): 173-181

7 Matsen FA III, Lippitt SB. Procedure: smooth and move-cuff intact. In: Matsen FA III, Lippitt SB, editors. Shoulder surgery: principles and procedures. Philadelphia: Saunders; 2008. p. 328-346

8 Magaji SA, Singh HP, Pandey RK. Arthroscopic subacromial decompression is effective in selected patients with shoulder impingement syndrome. J Bone Joint Surg Br 2012; 94(8): 1086-1089

9 Budoff JE, Nirschl RP, Guidi EJ. Débridement of partialthickness tears of the rotator cuff without acromioplasty. Long-term follow-up and review of the literature. J Bone Joint Surg Am 1998; 80: 733-748

10 Blevins FT, Warren RF, Cavo C, Altchek DW, Dines D, Palletta G, Wickiewicz TL.Arthroscopic assisted rotator cuff repair: Results using a mini-open deltoid splitting approach. Arthroscopy 1996; 12: 50-59

11 Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am 1998; 80: 832-840

12 Romeo AA, Hang DW, Bach BR Jr, Shott S. Repair of full thickness rotator cuff tears. Gender, age, and other factors affecting outcome. Clin Orthop Relat Res 1999: 243-255

13 Budoff JE, Nirschl RP, Guidi EJ. Current concepts review - de´bridement of partial-thickness tears of the rotator cuff without acromioplasty. Long-term follow-up and review of the literature. J Bone Joint Surg Am 1998; 80(5): 733-748

14 Huisstede BM, Miedema HS, Verhagen AP. Multidisciplinary consensus on the terminology and classification of complaints of the arm, neck and/or shoulder. Occup Environ Med 2007; 64(1): 313-319

15 Ketola S, Lehtinen J, Arnala I, Nissinen M, Westenius H, Sintonen H, Aronen P, Konttinen YT, Malmivaara A, Rousi T. Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a two-year randomised controlled trial. J Bone Joint Surg Br 2009; 91(10): 1326-1334

16 Henkus HE, de Witte PB, Nelissen RG, Brand R, van Arkel ER. Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study. J Bone Joint Surg Br 2009; 91(4): 504-510

17 Haahr JP, Andersen JH. Exercises may be as efficient as subacromial decompression in patients with subacromial stage II impingement: 4-8-years’ follow-up in a prospective, randomized study. Scand J Rheumatol 2006; 35(3): 224-228

18 Shin SJ, Oh JH, Chung SW, Song MH. The efficacy of acromioplasty in the arthroscopic repair of small- to medium-sized rotator cuff tears without acromial spur: prospective comparative study. Arthroscopy. 2012; 28(5): 628-635

19 MacDonald P, McRae S, Leiter J, Mascarenhas R, Lapner P. Arthroscopic Rotator Cuff Repair with and without Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears. J Bone Joint Surg (Am) 2011; 93: 1953-1960

20 Abrams GD, Gupta AK, Hussey KE, Tetteh ES, Karas V, Bach BR, Cole BJ, Romeo AA, Verma NN. Arthroscopic Repair of Full-Thickness Rotator Cuff Tears With and Without Acromioplasty. Am J Sports Med 2014 14; 42(6): 1296-1303

21 Bollier M, Shea K. Systematic review: what surgical technique provides the best outcome for symptomatic partial articular-sided rotator cuff tears? Iowa Orthop J 2012; 32: 164-172

22 Lee BG, Cho NS, Rhee YG. Results of arthroscopic decompression and tuberoplasty for irreparable massive rotator cuff tears. Arthroscopy 2011 Oct; 27(10): 1341-1350

23 Chahal J, Mall N, MacDonald PB, Van Thiel G, Cole BJ, Romeo AA, Verma NN. The role of subacromial decompression in patients undergoing arthroscopic repair of full-thickness tears of the rotator cuff: a systematic review and meta-analysis. Arthroscopy 2012; 28(5): 720-727

Peer reviewers: Maurice Balke, Department of Sportstraumatology, Cologne Merheim Medical Center, University of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Köln, Germany; Jia-Guo Zhao, MD, Department of Orthopaedic Surgery, Tianjin Hospital, No. 406 Jiefang South Road, Hexi District, Tianjin 300211, China.

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