Arthroscopic Acromioplasty Research Articles

Indications and techniques of arthroscopic anterior and lateral acromioplasty

Arthroscopic anterior acromioplasty (AAAP) for treatment of symptomatic subacromial spur. Arthroscopic lateral acromioplasty (ALAP) to reduce apathological critical shoulder angle (CSA) and prevent rotator cuff re-tear after reconstruction. AAAP is indicated for acromial impingement due to an anterolateral acromial spur with or without bursa-sided rotator cuff lesion. ALAP is indicated concomitant to arthroscopic rotator cuff repair if the CSA is pathologically increased. Irreparable rotator cuff tear with acetabularization of the acromion due to anterosuperior escape of the humeral head or symptomatic os acromiale can contraindicate for AAAP. Dehiscence of the origin of the deltoid muscle or symptomatic os acromiale can contraindicate for ALAP. To preform AAAP, arthroscopic subacromial decompression is followed by anterolateral resection of an acromion spur or ossification of the coracoacromial ligament. To perform ALAP, arthroscopic subacromial decompression and reconstruction of arotator cuff-tear is followed by reduction of apathologically increased CSA by resection of the lateral edge of the acromion. After isolated AAAP, physiotherapy can be performed without restriction. After AAAP or ALAP combined with rotator cuff repair, immobilization in abrace is recommended. The use of pain medication should be standardized and adapted to individual pain levels.

Attrition of rotator cuff without progression to tears during 2-5years of conservative treatment for impingement syndrome.

The purpose of this study was to investigate the natural history of intact rotator cuff in impingement syndrome patients with concomitant spur protruding from the undersurface of acromion. This retrospective study included 119 patients with an intact rotator cuff who underwent conservative treatment for a spur protruding from the undersurface of the acromion. The protruded spur was defined as a trapezoid- or tetragon-shaped bony protrusion with a downward peak extending more than 3mm in length from the baseline drawn along the acromial undersurface on the coronal view of magnetic resonance imaging (MRI) or computed tomography arthrography (CTA). Functional outcomes were evaluated by the visual analogue scale for pain, subjective shoulder value, American Shoulder and Elbow Surgeons score, University of California Los Angeles shoulder score, and active range of motion (ROM). To evaluate cuff integrity, follow-up MRI, CTA, or ultrasound were performed at least 2years after the initial presentation. No new rotator cuff tears were noted in any patient during the follow-up imaging studies. However, 18 patients (15%) underwent arthroscopic acromioplasty during the study period. During the arthroscopic examinations, moderate to severe attrition of the cuff was identified, although no tears were seen. At the final follow-up, pain level and shoulder function, including ROM, showed satisfactory outcomes. Spurs protruding from the acromial undersurface did not lead to rotator cuff tears during 2-5years of conservative treatment. However, attrition of the rotator cuff was found during arthroscopic acromioplasty, suggesting that the protruding spurs caused extrinsic impingement of the cuff. Therapeutic case series Level IV.

ARTHROSCOPIC ACROMIOPLASTY FOR TREATMENT OF SHOULDER IMPINGEMENT SYNDROME

Background: The technique of arthroscopic subacromial decompression (ASD) is an effective alternative to the open operation. The arthroscopic procedure is technically demanding. Patients and methods: Between January 2016 and February 2018, sixteen male patients, who fulfilled the criteria of the subacromial impingement syndrome, underwent arthroscopy, stability testing under anesthesia and arthroscopic acromioplasty. Pain was the chief complaint of every patient in this study. We used modified UCLA shoulder rating scale for clinical evaluation of the all patients. Pre-operative radiographs included an AP and axillary views added to 30° caudal tilt view or a supraspinatus outlet view were done routinely. MRI of the shoulder was done for all cases. Results: Satisfactory results were achieved in all patients and 6 of them were excellent according to UCLA score. Eight patients had good results and two fair, but no poor results were found in this study up to one year postoperative. Pain relief was the most dramatic benefit but function also improved. The subacromial space of the patients was filled with hypertrophic fibrous bands of bursal stroma, often with fibro-fatty tissue. Hyperemia was often observed. Surface ulcerations were identified on the rotator cuff in 8 cases. Rotator cuff partial tear in 4 cases. Conclusion: In cases of primary impingement, calcific tendinitis, or partial thickness rotator cuff tears the arthroscopic acromioplasty and decompression, is the procedure of choice provided that no shoulder instability. The right indications and skilled hands, the results are better than the results of open acromioplasty, as the patients recover faster with less risk of deltoid muscle complications.

Subacromial Decompression Yields a Better Clinical Outcome Than Therapy Alone: A Prospective Randomized Study of Patients With a Minimum 10-Year Follow-up

Background: The long-term outcome after the treatment of subacromial impingement syndrome (SAIS) with either nonsurgical or surgical methods has not been thoroughly investigated. Hypothesis/Purpose: The purpose was to evaluate the long-term clinical outcome and the presence of rotator cuff injuries and osteoarthritis (OA) after the surgical and nonsurgical treatment of SAIS. The hypothesis was that, at a minimum 10 years after the initial treatment, patients who had undergone acromioplasty would have a better clinical outcome and run a lower risk of developing rotator cuff ruptures and OA as compared with those treated with physical therapy. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Eighty-seven patients with SAIS were randomized to 3 groups: open acromioplasty (open surgery group [OSG]), arthroscopic acromioplasty (arthroscopic surgery group [ASG]), and nonsurgical treatment (physical therapy group [PTG]). The Constant score, the Watson and Sonnabend score, and the 36-Item Short Form Health Survey (SF-36) questionnaire were used as outcome measurements. Furthermore, bilateral ultrasound examinations were performed to detect rotator cuff ruptures and bilateral radiographs to detect OA. Sixty-six patients (76%) attended the clinical follow-up at least 10 years after the initial treatment. Results: The groups were demographically comparable at baseline. The Constant score improved significantly at follow-up for the OSG (P = .003) and ASG (P = .011), while no significant improvement was detected for the PTG. The OSG revealed a significant improvement versus the PTG at follow-up (P = .011); otherwise, no significant differences were found. For the Watson and Sonnabend score, the OSG revealed a significant improvement in 13 of 14 questions. The corresponding finding was made for the ASG and PTG in 9 of 14 questions (P = .14). According to ultrasound, 1 of 20 patients in the OSG had a full-thickness rotator cuff rupture on the index side. The corresponding finding was made for 1 of 18 patients in the ASG and 4 of 28 in the PTG (P = .29). Per the radiographs, 3 of 20 patients in the OSG had moderate or severe OA in the index shoulder. The corresponding finding was made for 1 of 18 patients in the ASG and 0 of 28 in the PTG (P = .12). Conclusion: After a minimum 10 years of follow-up, the surgical treatment of SAIS appears to render better clinical results than physical therapy alone. No significant differences were found among the groups in terms of the presence of full-thickness rotator cuff ruptures and OA.

Arthroscopic Correction of the Critical Shoulder Angle Through Lateral Acromioplasty: A Safe Adjunct to Rotator Cuff Repair

To investigate whether arthroscopic lateral acromioplasty reliably decreases the critical shoulder angle (CSA) and whether it is associated with damage to the deltoid or other complications. Patients undergoing arthroscopic rotator cuff repair (RCR) with lateral but without anterior acromioplasty for degenerative, full-thickness rotator cuff tears and a CSA of 34° or greater were retrospectively reviewed. Patients with traumatic or irreparable rotator cuff tears, osteoarthritis, or previous surgery were excluded. Clinical and radiographic outcomes were assessed at a minimum of 12months' follow-up. We reviewed 49 consecutive patients (mean age, 56years; age range, 39-76years) at a mean of 30months (range, 12-47months). There were 7 RCR failures (14%). The mean CSA was reduced from 37.5° preoperatively (95% confidence interval [CI], 36.7°-38.3°) to 33.9° postoperatively (95% CI, 33.3°-34.6°; P < .001). There were no cases of dehiscence, increases in fatty infiltration, or significant atrophy of the deltoid. Scarring at the deltoid origin was noted in 18 patients (37%). The mean absolute and relative Constant scores increased from 59 points (95% CI, 54-64 points) to 74 points (95% CI, 70-78 points) and from 66% (95% CI, 61%-71%) to 83% (95% CI, 79%-87%) respectively, and the Subjective Shoulder Value increased from 45% (95% CI, 39%-50%) to 80% (95% CI, 74%-86%) (P< .001 for all 3 improvements). The postoperative CSA was significantly larger in failed than in healed repairs (P= .026). Patients with a healed RCR and a CSA corrected to 33° or less (n= 22) had 25% more abduction strength than patients with a healed cuff and a CSA corrected to 35° or greater (n= 14, P= .04). Arthroscopic lateral acromioplasty performed in addition to arthroscopic RCR can reduce the CSA without significantly compromising the deltoid origin, deltoid muscle, or function. It is not associated with any additional complications of arthroscopic RCR. Insufficiently corrected, abnormally large CSAs are associated either with a higher retear rate or with inferior strength of abduction if the tears heal. Level IV, case series, treatment study.

Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy: a final review of a randomised controlled trial at a minimum follow-up of ten years.

Rotator cuff tendinopathy has a multifactorial origin. Rejecting the mechanistic theory has also led to abandoning operative treatment at initial presentation in the first line. Physiotherapy exercise programmes are the accepted first line treatment. The aim of this study was to assess the long-term additional benefits of subacromial decompression in the treatment of rotator cuff tendinopathy. This randomised controlled trial of 140 patients (52 men, 88 women, mean age 47.1 years; 18 to 60) with rotator cuff tendinopathy extended previous work up to a maximum of 13 years. The patients were randomised into two treatment groups: arthroscopic acromioplasty and a supervised exercise treatment and a similar supervised exercise treatment alone. Self-reported pain on a visual analogue scale (VAS) was the primary outcome measure. Secondary measures were disability, working ability, pain at night, Shoulder Disability Questionnaire score and the number of painful days during the three months preceding the final assessment. A total of 90 patients (64%) returned questionnaires at a mean 12 years after randomisation. On an intention-to-treat basis, both treatment groups reached statistically significant improvement compared with the initial VAS for pain, but there was no significant difference between groups. The same was true in the secondary outcome measures. Due to group changes, the results were also analysed per protocol: operated or not. No significant differences between the groups were found. The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results. In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy. Cite this article: Bone Joint J 2017;99-B:799-805.

Does acromioplasty result in favorable clinical and radiologic outcomes in the management of chronic subacromial pain syndrome? A double-blinded randomized clinical trial with 9 to 14 years' follow-up

The treatment effect of acromioplasty for chronic subacromial pain syndrome (SAPS) on long-term shoulder function and rotator cuff deterioration has still to be determined. This study aimed to determine the long-term clinical and radiologic treatment effect of arthroscopic acromioplasty in patients with chronic SAPS. In this double-blind, randomized clinical trial, 56 patients with chronic SAPS (median age, 47 years; age range, 31-60 years) were randomly allocated to arthroscopic bursectomy alone or to bursectomy combined with acromioplasty and were followed up for a median of 12 years. The primary outcome was the Constant score. Secondary outcomes included the Simple Shoulder Test, visual analog scale (VAS) for pain, VAS for shoulder functionality, and rotator cuff integrity assessed with magnetic resonance imaging or ultrasound. A total of 43 patients (77%) were examined at a median of 12 years' follow-up. Intention-to-treat analysis at 12 years' follow-up did not show a significant additional treatment effect of acromioplasty on bursectomy alone in improvement in Constant score (5 points; 95% confidence interval, -5.1 to 15.6), Simple Shoulder Test score, VAS score for pain, or VAS score for shoulder function. The prevalence of rotator cuff tears was not significantly different between the bursectomy group (17%) and acromioplasty group (10%). There were no relevant additional effects of arthroscopic acromioplasty on bursectomy alone with respect to clinical outcomes and rotator cuff integrity at 12 years' follow-up. These findings bring the effectiveness of acromioplasty into question and may support the idea of a more conservative approach in the initial treatment of SAPS.

Subacromial Decompression in Patients with Impingement Syndrome Results in Better Clinical Outcome Compared to Physiotherapy in the Long Term. A Prospective Randomised Study

Objectives:The long-term outcome after treatment of subacromial impingement syndrome (SAIS) with either non-surgical or surgical methods is not thoroughly investigated. The purpose of this study was to evaluate the long-term clinical outcome, the presence of rotator-cuff injuries and osteoarthritis after both surgical and non-surgical treatment.Methods:Eighty-seven patients with SAIS were randomised to three groups: open acromioplasty (OSG), arthroscopic acromioplasty (ASG) or physiotherapy (PTG). The Constant score and the Watson & Sonnabend score were used as outcome measures. Furthermore, bilateral ultrasound examinations to detect rotator-cuff ruptures and bilateral x-rays to detect osteoarthritis were performed. Sixty-six patients (76%) attended the clinical follow-up, 14 (SD 1.5) years after the initial treatment.Results:The groups were demographically comparable at baseline. The Constant score had improved significantly at follow-up in both the OSG and the ASG (p=0.003 and 0.011 respectively). No improvement was detected in the PTG. The OSG revealed a significant improvement compared to the PTG at follow-up (p=0.011), otherwise no significant differences were found. For the Watson & Sonnabend score the OSG revealed significant improvement in 13/14 questions. The corresponding was found in the ASG and the PTG in 9/14 questions (p=0.14). Using ultra-sound 1/20 patients in the OSG revealed a full-thickness rotator cuff rupture on the index side. The corresponding was found for 1/18 in the ASG and 4/28 in the PTG (p=0.29). On the contralateral side 2/20 patients in the OSG revealed a full-thickness rotator cuff tear. The corresponding was found for 1/18 in the ASG and 4/28 in the PTG (p=0.36). On the x-rays 3/20 patients in the OSG revealed moderate or severe osteoarthritis in the index shoulder. The corresponding was found for 1/18 in the ASG and 0/28 in the PTG (p=0.12). 1/20 patients in the OSG revealed osteoarthritis in the contra-lateral shoulder. The corresponding was found for 1/18 in the ASG and 0/28 in the PTG (p=0.11).Conclusion:In the long term surgical treatment of SAIS appears to render better clinical results than physiotherapy. No significant differences were found between the groups in terms of the presence of full thickness rotator cuff ruptures and osteoarthritis.

Arthroscopic Excision of a Symptomatic Meso-acromiale

The surgical technique for the management of a symptomatic os acromiale remains unclear. Several operative techniques have been described including open excision, open reduction–internal fixation (ORIF), arthroscopic acromioplasty or subacromial decompression, and arthroscopic excision. There are 4 types of os acromiale, with the meso-acromion being the most common and difficult to treat. The excision of a pre-acromion arthroscopically or in an open manner usually produces satisfactory results. However, the open excision of a meso-acromion can lead to persistent pain and deltoid weakness and atrophy. The management of a meso-acromial fragment with ORIF can also result in persistent pain and deltoid weakness and atrophy with nonunion of the fragments. The purpose of this article is to describe an alternative surgical technique to open excision or ORIF when presented with a symptomatic meso-acromiale.

The comparison of arthroscopic acromioplasty with and without acromioclavicular coplaning.

Coplaning means the removal of medial acromial spurs and inferior aspect of the distal clavicle. The aim of the study was to evaluate the outcomes of arthroscopic acromioplasty with and without coplaning in patients without acromioclavicular (AC) joint arthritis. Because of impingement syndrome, arthroscopic subacromial decompression and acromioplasty was performed in Group 1 (9 males/31 female). In addition, coplaning was performed in Group 2 (8 males/21 females) by two different surgeons. The mean age was 48 in Group 1, 46 in Group 2. The mean follow-up was 50 months and 44 months, respectively. Constant score, cross-body adduction test and AC joint tenderness was used for follow-up. The mean preoperative Constant scores were 45 points (range: 34-76 points) in Group 1, 39 points (range: 32-69 points) in Group 2. The mean Constant scores at the latest follow-up was 78 points (range: 68-100 points) for Group 1, 84 points (range: 72-100 points) for Group 2. There was no statistically difference between two groups at the latest follow-up (p<0.05). In two patients in Group 2, cross-body adduction test was positive but asymptomatic. Excision of the inferior side of the lateral clavicle to the level of the acromion with minimal disruption of the joint capsule does not develop AC joint symptoms in long-term follow-up.

Impact of Arthroscopic Lateral Acromioplasty on the Mechanical and Structural Integrity of the Lateral Deltoid Origin: A Cadaveric Study

To determine whether a 5-mm and/or 10-mm arthroscopic lateral acromioplasty (ALA) would weaken the structural and mechanical integrity of the lateral deltoid. The acromion and lateral deltoid origin were harvested from 15 pairs (n= 30) of fresh-frozen human cadaveric shoulder specimens. One side of each specimen pair (left or right) was randomly assigned to either a 5-mm (n= 7) or 10-mm (n= 8) ALA group, and the contralateral sides (n= 15) were used as matched controls. Acromion thickness and width were measured pre- and postoperatively. After ALA, specimens were inspected for damage to the lateral deltoid origin. Each specimen was secured within a dynamic testing machine, and the deltoid muscle was pulled to failure. Statistical analysis was performed to determine whether ALA reduced the lateral deltoid's failure load. There was no significant difference in failure load between the 5-mm ALA group (661 ± 207N) and its matched control group (744 ± 212N; mean difference= 83N; 95% confidence interval [CI], -91 to 258; P= .285) nor between the 10-mm ALA group (544 ± 210N) and its matched control group (598 ±157N; mean difference= 54N; 95% CI, -141 to 250; P= .532). There was no correlation found between the amount of bone resected (measured by percent thickness and width of the acromion after ALA) and the failure load of the deltoid. Visual evaluation of the acromion after ALA revealed the lateral deltoid origin had no damage in any case. ALA did not weaken the structural or mechanical integrity of the lateral deltoid origin. Neither a 5-mm nor a 10-mm ALA significantly reduced the deltoid's failure load. The lateral deltoid origin was not macroscopically damaged in any case. ALA can be performed without the potential risk of macroscopically damaging the lateral deltoid origin or reducing its failure load.

No difference in long-term development of rotator cuff rupture and muscle volumes in impingement patients with or without decompression

Background and purpose — Arthroscopic acromioplasty is still commonly used in the treatment of shoulder impingement syndrome, even though its benefits are questioned; randomized controlled studies have not shown any benefits when compared to non-operative treatment. In this randomized study, we investigated whether operative treatment protects from later rotator cuff rupture and whether it has any effect on the development of rotator cuff muscle volume.Patients and methods — 140 stage-II impingement patients were randomized to a structured exercise group (n = 70) or to an operative group (n = 70). In the operative group, arthroscopic acromioplasty was performed, after which a similar structured exercise program was begun. MRI of the shoulder was done at baseline and at 5 years.Results — There were no statistically significant differences in either the amount of perforating ruptures of the supraspinatus tendon or in the changes in muscle volume at 5 years. The grading of muscle fatty degeneration showed worse results in the operative group, but this difference was not statistically significant.Interpretation — In this study, we found that arthroscopic acromioplasty does not have any long-term benefit based on radiological findings of muscle volumes. Also, the frequency of later rotator cuff rupture was similar irrespective of whether or not surgery was performed. Acromioplasty is not justified as a treatment for dynamic shoulder impingement syndrome.

Profile of Current Opinion on Arthroscopic Acromioplasty: A Video Survey Study

To provide a baseline profile of current opinion on use of arthroscopic acromioplasty and evaluate the consistency of surgical decision making on whether or not to perform acromioplasty across different surgeon practices. Twenty-two fellowship-trained orthopaedic shoulder surgeons from the Association of Clinical Elbow and Shoulder Surgeons completed an Internet-based survey on practices associated with acromioplasty, including questions related to 15 arthroscopic videos. Based on video cases, interobserver and intraobserver agreement regarding clinically based decisions related to acromioplasty were assessed. Acromioplasty was uncommonly performed in isolation among this group and was most commonly performed in conjunction with repair of full-thickness rotator cuff tears. Nineteen of 22 (86%) surgeons favored an arthroscopic approach for acromioplasty. Depth of bony resection was determined most commonly based on clinical judgment and experience (68%). The video portion of the survey revealed slight interobserver agreement for classification of acromion morphology (κ= 0.099), need for acromioplasty (κ= 0.020), and adequacy of decompression (κ= 0.1). In contrast, there was fair intraobserver reliability regarding acromion morphology (κ= 0.370) and decision whether to perform acromioplasty in a given case (κ= 0.348) whereas there was moderate intraobserver reliability inthe presence of a reparable rotator cuff tear (κ= 0.507) and assessment of the adequacy of decompression (κ= 0.453). Although surgeons had similarities regarding principles of acromioplasty, including indications, surgical approach, and technique, there was lack of consensus when surgeons reviewed the video of clinical cases. Although surgeons may have similar goals in terms of treatment of pathology related to subacromial impingement, individual surgeon thresholds for the need and adequacy of decompression are varied and are not standardized. Level V, expert opinion.

The Effects of Arthroscopic Lateral Acromioplasty on the Critical Shoulder Angle and the Anterolateral Deltoid Origin: An Anatomic Cadaveric Study

To investigate if (1) an anterolateral acromioplasty and (2) a lateral acromion resection alter the critical shoulder angle (CSA) without affecting the deltoid origin. First, the native CSAs of 10 human cadaveric shoulders (6 male and 4 female specimens; mean age, 54.2 years) were determined with the use of fluoroscopy. Setup allowed for consistent repetitive measurements. Next, a standard arthroscopic anterolateral acromioplasty was performed to create a type 1 acromion, and the CSA was reassessed fluoroscopically. Afterward, a lateral acromioplasty was performed with a 5-mm lateral acromion resection using a 5-mm burr, and the CSA was measured again. The native CSA was compared with (1) the CSA after acromioplasty and (2) the CSA after acromioplasty and lateral acromion resection using a paired t test. Finally, the acromial deltoid attachment was evaluated anatomically for damage to the anterolateral origin. The mean native CSA (34.3° ± 2.1°) was reduced significantly by acromioplasty (33.1° ± 2.0°, P < .001) and further reduced by lateral acromion resection (31.5° ± 1.7°, P < .001). Anterolateral acromioplasty reduced the CSA by a mean of 1.4° (95% confidence interval boundaries, 0.8° and 1.9°), and in combination with lateral acromion resection, the CSA was reduced by a mean of 2.8° (95% confidence interval boundaries, 2.1° and 3.5°). In all specimens (5 of 5) with a presurgery CSA of 35° or greater, the CSA was reduced to the range of 30° to 35° by the combination of both techniques. However, in 2 specimens with a CSA of approximately 32°, the CSA was reduced to less than 30°. The acromial deltoid attachment was found to be well preserved in all specimens. Arthroscopic anterolateral acromioplasty and a 5-mm lateral acromion resection each reduced the CSA significantly and did not damage the deltoid origin. The combination of both techniques could potentially be used in clinical practice to reduce a CSA greater than 35° to the desired range of 30° to 35°.

Platelet-Rich Plasma Injection With Arthroscopic Acromioplasty for Chronic Rotator Cuff Tendinopathy

Background: Platelet-rich plasma (PRP) has been proposed to augment tendon healing through improving tissue structure during the initial repair phase. Purpose: To investigate both the clinical and tissue effects of the coapplication of PRP injection with arthroscopic acromioplasty (AA) in patients with chronic rotator cuff tendinopathy. Design: Randomized controlled trial; Level of evidence, 1. Methods: The study comprised 60 randomized patients diagnosed with rotator cuff tendinopathy (55% women) aged between 35 and 75 years. Patients were randomized to AA alone or in combination with an injection of autologous PRP into the subacromial bursa (AA + PRP). Efficacy of treatment was assessed by analysis of patient-reported outcomes up to 2 years after treatment (Oxford Shoulder Score [OSS]) and by analysis of tendon biopsy specimens taken 12 weeks after treatment. Results: There was no significant difference in the OSS between AA alone and AA + PRP at any time point in the study. From 12 weeks onward, there was a significant increase in the OSS for both groups compared with their baseline scores (P < .001). Bonar scoring determined no significant change in tissue structure with the coapplication of PRP compared with surgery alone. The number of blood vessels and tendon cellularity were significantly decreased in tissue biopsy specimens taken from PRP-treated patients. The expression of p53-positive apoptotic cells increased after AA + PRP but decreased after AA alone. Conclusion: Arthroscopic acromioplasty significantly improves long-term clinical outcomes up to 2 years. The coapplication of PRP did not affect clinical outcomes. PRP significantly alters the tissue characteristics in tendons after surgery with reduced cellularity and vascularity and increased levels of apoptosis. Clinical Relevance: The coapplication of PRP did not improve clinical outcomes and may have potential deleterious effects on healing tendons. Registry Number: ISRCTN 10464365

Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment?

Background and purpose — Shoulder impingement syndrome is common, but treatment is controversial. Arthroscopic acromioplasty is popular even though its efficacy is unknown. In this study, we analyzed stage-II shoulder impingement patients in subgroups to identify those who would benefit from the operation.Patients and methods — In a previous randomized study, 140 patients were either treated with a supervised exercise program or with arthroscopic acromioplasty followed by a similar exercise program. The patients were followed up at 2 and 5 years after randomization. Self-reported pain was used as the primary outcome measure.Results — Both treatment groups had less pain at 2 and 5 years, and this was similar in both groups. Duration of symptoms, marital status (single), long periods of sick leave, and lack of professional education appeared to increase the risk of persistent pain despite the treatment. Patients with impingement with radiological acromioclavicular (AC) joint degeneration also had more pain. The patients in the exercise group who later wanted operative treatment and had it did not get better after the operation.Interpretation — The natural course probably plays a substantial role in the outcome. Based on our findings, it is difficult to recommend arthroscopic acromioplasty for any specific subgroup. Regarding operative treatment, however, a concomitant AC joint resection might be recommended if there are signs of AC joint degeneration. Even more challenging for the development of a treatment algorithm is the finding that patients who do not recover after nonoperative treatment should not be operated either.

Tips and Technical Pearls for Performing an Arthroscopic Acromioplasty in a Reproducible and Accurate Manner

Tips and Technical Pearls for Performing an Arthroscopic Acromioplasty in a Reproducible and Accurate Manner

Comparison of open acromioplasty, arthroscopic acromioplasty and physiotherapy in patients with subacromial impingement syndrome: a prospective randomised study

To compare the results two to three years after intervention, using either surgical or non-operative treatment. Eighty-seven patients with subacromial impingement syndrome (SAIS) were randomised into open acromioplasty (OS group), arthroscopic acromioplasty (AS group) or physiotherapy (PT group) treatment. The assessments comprised the Constant score, the Watson and Sonnabend score, the SF-36 evaluation and a clinical examination performed by an independent observer. Fifty-five patients attended the clinical follow-up. The groups were comparable at baseline in terms of demographics and clinical assessments. No significant differences in terms of the clinical assessments or health-related quality of life (QoL) were found between the study groups at follow-up. The Constant score had improved significantly at follow-up in both the OS group and the AS group (p=0.003 and 0.008, respectively). At follow-up, the OS group revealed improved strength compared with before intervention (p=0.012). All groups revealed a significantly improved internal rotation (OSG p=0.01, ASG p=0.005, PTG p=0.004). The SF-36 was significantly improved in some scales within all three groups. The Watson and Sonnabend score was significantly improved in 12/14 questions for the OS group, in 5/14 questions for the AS group and in 6/14 for the PT group (p<0.02 OS group vs. AS group, p<0.05 OS group vs. PT group). In this randomised study, the Constant score, other clinical assessments and subjective health-related QoL revealed no significant differences between the 3 groups two to three years after intervention in patients with SAIS. The OS group showed a greater improvement over time. CT with low follow-up rate, Level II.

Financial impact of third-party reimbursement changes for CPT Code 29826: experience of a large group practice.

On January 1, 2012, the Centers for Medicare & Medicaid Services converted Current Procedural Terminology (CPT) code 29826 (arthroscopic acromioplasty) from a stand-alone code to an add-on code and reduced the relative value units from 19.58 to 5.24. The goal of this study was to quantify the financial impact of this change on a large single-specialty orthopaedic surgery practice. Custom software was used to query the database that harbors billing data for a large single-specialty orthopaedic group. Data were independently generated based on patient identification data and insurance class, and compared between 2011 and 2012. Codes 29826, 29827 (shoulder arthroscopy, rotator cuff repair), 29822 (shoulder arthroscopy, debridement, limited), 29823 (shoulder arthroscopy, debridement, extensive), and 29824 (shoulder arthroscopy, distal claviculectomy) were all searched independently for each year and cross-referenced with each other and all other shoulder codes. Modifier codes for surgical assistants were analyzed separately and subsequently combined with primary surgeon data for financial analysis. This included assessment of surgeon reimbursement per occurrence of code 29826 and surgeon reimbursement by Medicare compared with non-Medicare payers. Code 29826 was used 1536 times in 2011 and 1410 times in 2012 (-2.59% after correcting for all shoulder arthroscopy cases per year). Code 29822 was used significantly more in 2012 both alone (1.45%, p = 0.001) and in total (2.45%), but the use of 29823 did not change (p = 0.17). A combination of three of the five selected codes was used significantly less in 2012 (p < 0.001), while the use of any combination of four codes was used significantly more in 2012 (p < 0.001). Assistant use did not appreciably change between years. Average reimbursement for code 29826 by all payers in 2011 was $456.84 and $441.64 in 2012. Average payment by Medicare was $268.58 in 2011 and $171.02 in 2012 (-36.3%). Medicare paid 54.3% of other payers per case in 2011 and 33.1% of other payers in 2012. Reimbursement for code 29826 by non-Medicare payers did not decrease dramatically between 2011 and 2012. However, Medicare reimbursement fell substantially.

Efficacy of surgery for rotator cuff tendinopathy: a systematic review

The objective of this study is to review randomized controlled trials evaluating the efficacy of surgery for the treatment of rotator cuff (RC) tendinopathy. Studies up to August 2013 were located in the PubMed, Embase, CINAHL, and PEDro databases using relevant keywords. Studies were included if: (1) participants had rotator cuff tendinopathy, (2) the trials were conducted on an adult population (≥18 years old), (3) at least one of the interventions studied was a surgical procedure, (4) study design was a randomized controlled trial (RCT), and (5) the article was written in English or French. Characteristics of the included studies were extracted using a standardized form. Two independent raters reviewed the methodological quality of the studies using the Risk of Bias Assessment tool developed by the Cochrane Collaboration Group. Differences were resolved by consensus. Fifteen trials met our inclusion criteria. After consensus, the mean methodological quality for all studies was 58.9 ± 10.8 %. In three out of four RCTs of moderate or low methodological quality, no significant difference in treatment effectiveness was observed between open or arthroscopic acromioplasty compared to exercises in the treatment of RC tendinopathy. Based on two studies of low or moderate methodological quality, no difference in treatment effectiveness was observed between arthroscopic and open acromioplasty. Two other RCTs of low to moderate quality, however, found that arthroscopic acromioplasty yielded better results in the short-term for shoulder range of motion in flexion but that both procedures were comparable in the long-term. One additional study favored open acromioplasty over arthroscopic acromioplasty for the treatment of RC tendinopathy. Based on low- to moderate-quality evidence, acromioplasty, be it open or arthroscopic, is no more effective than exercises for the treatment of RC tendinopathy. Low-grade evidence also suggests that arthroscopic acromioplasty may yield better results in the short-term for shoulder range of motion in flexion compared to open acromioplasty, but long-term results are comparable between the two types of surgery. More high-quality RCTs are required in order to provide comprehensive treatment guidelines to healthcare providers.