Arthroscopic Acromioplasty Research Articles

Vanishing distal clavicle after arthroscopic acromioplasty

Summary: Arthroscopic subacromial decompression is gaining wide acceptance. There are several reports on its technique, its limitations, and its efficacy. However, papers describing complications are rare. We describe a case of osteolysis of the distal clavicle after overenthusiastic arthroscopic subacromial decompression.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 8 (November-December), 2000: pp 855–857

Arthroscopic decompression for impingement syndrome secondary to an unstable os acromiale

Purpose: The purpose of this study was to examine cases of patients with impingement syndrome secondary to an unfused, unstable, os acromiale. Type of Study: Retrospective case series. Materials and Methods: Twelve consecutive patients (13 shoulders) presented with impingement symptoms in the presence of an os acromiale. The os acromiale, at the meso-acromion level, was seen on standard radiographs. The patients were all treated conservatively with rotator cuff strengthening, stretching, anti-inflammatory medications, and steroid injections. All patients underwent an impingement test with lidocaine, resulting in complete relief of their pain. After failure of the conservative management, the 12 patients (13 shoulders) underwent an extended arthroscopic subacromial decompression. The goal of the modified arthroscopic acromioplasty was resection of adequate bone to remove the mobile anterior acromial tip. In general, this consisted of more bony resection than the typical arthroscopic acromioplasty. Postoperatively, the patients began a rehabilitation program emphasizing early range of motion followed by isolated free-weight rotator cuff strengthening exercises. Five shoulders had a partial-thickness tear of the rotator cuff. Four involved less than 50% of the thickness of the rotator cuff. These 4 partial-thickness tears underwent arthroscopic rotator cuff debridement. One partial-thickness tear was greater than 50% and repair was performed with a mini-open deltoid-splitting technique. Results: Results were evaluated using UCLA shoulder scoring. Preoperatively, the score averaged 17. The 3-month postoperative score was 27, and at 6 and 12 months, averaged 28. The final follow-up score averaged 31. There were 11 satisfactory results with UCLA scores ≥28. Two unsatisfactory results showed UCLA scores in the fair category. Full strength of the anterior deltoid and rotator cuff muscles was achieved in all patients by 6 months postoperatively as evaluated by manual muscle testing. Twelve of the 13 shoulders were rated by the patients as having a satisfactory result. All of the patients rated their cosmetic results as acceptable. There was no evidence of postoperative deltoid detachment. No patient developed pain at the pseudarthrosis point. Conclusions: Given the previously reported poor results with attempts at fusion of an unstable os acromiale and open complete excision of meso-acromial fragments, the authors conclude that an extended arthroscopic subacromial decompression results in a reasonable outcome for patients with impingement syndromes secondary to an unstable os acromiale.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 6 (September), 2000: pp 595–599

Intramuscular pressure and fluid absorption during arthroscopic acromioplasty

During arthroscopic acromioplasty a high level of irrigation fluid pressure is sometimes required to obtain an adequate visual field. To evaluate the influence of bursa pressure level on the blood circulation of the shoulder muscles, we measured the intramuscular pressure (IMP) in the supraspinatus and deltoid muscles with the microcapillary infusion technique during surgery. Eleven patients with impingement syndromes Neer I–III and rotator cuff tendinitis were examined at subacromial bursa pressures of 100 or 150 mm Hg. In another 11 patients the amount of irrigation fluid absorbed into the circulatory system was evaluated with the use of 2% ethanol NaCl irrigation fluid. At bursal pressures of 100 or 150 mm Hg, the absorbed volume was calculated from the expiratory breath ethanol concentration at the termination of surgery. The IMP in both the supraspinatus and the deltoid muscle varied considerably regardless of bursal pressure. In 50% of the recordings a considerable increase was seen in IMP pressure (>15 mm Hg) when the arthroscope was redirected from the intra-articular position to the subacromial bursa. The mean IMP in both muscles was less than 60 mm Hg during the major portion of the bursoscopy regardless of the infusion pressure level. The fluid absorption was 100 mL (0 to 229 mL) in the 100 mm Hg group and 37 mL (0 to 180 mL) in the 150 mm Hg group. All values were well below the 1000 mL absorption limit regarding the risk of development of a hyperhydration syndrome. In arthroscopic acromioplasty a bursal pressure of 100 or 150 mm Hg will result in similar IMP levels, in most cases below the threshold for muscle blood circulation. The amount of fluid absorbed to the circulatory system will be harmless.

Severe heterotopic ossification after arthroscopic acromioplasty: A case report

Heterotopic ossification is a well-recognized complication of spinal cord injury, closed head injury, total hip arthroplasty, burns, and other trauma and has been observed in various tissues such as muscles, tendons, ligaments, and menisci. Complications of arthroscopic acromioplasty are relatively uncommon and include hematoma, traction neuropathy, infection, acromial fracture, reflex sympathetic dystrophy, and instrument breakage. However, little has been reported on heterotopic ossification of the shoulder, particularly after arthroscopic surgery. Recurrent rotator cuff impingement symptoms caused by small amounts of heterotopic ossification after arthroscopic acromioplasty have been described. We report a case of severe heterotopic ossification about the shoulder after arthroscopic acromioplasty.

Cost-benefit comparison: Holmium laser versus electrocautery in arthroscopic acromioplasty

This prospective study was designed to measure the costs and benefits of using a laser rather than electrocautery for soft tissue resection during arthroscopic shoulder decompression. Forty-nine shoulders with refractory Neer stage II impingement (persistent fibrosis and tendinitis) were divided into 2 groups. The composition of the 2 groups was similar with regard to sex, worker's compensation status, dominant arm involvement, duration of symptoms, and length of conservative treatment. In one group, electrocautery was used to ablate the bursa and periosterum, release the coracoacromial ligament, and maintain hemostasis. In the other group, a laser was used in place of electrocautery. Patients had been evaluated preoperatively with 2 functional scoring systems. The patients were reexamined at 1 week and at 1, 2, 3, 6, and 12 months after surgery. There were no differences between the groups with regard to functional outcome or satisfaction. There was also no difference in terms of estimated blood loss or operative time. However, there was a statistically significant difference in total hospital charges between groups, with the laser group having a 23% higher hospital bill. On the basis of these results, it is concluded that there was no medical benefit to laser-assisted arthroscopic subacromial decompression but there was an increased monetary cost.

Arthroscopic Debridement and Acromioplasty Versus Mini-Open Repair in the Treatment of Significant Partial-Thickness Rotator Cuff Tears

Summary: Partial tears of the rotator cuff, especially of the articular side, have received attention only with the recent ability of magnetic resonance imaging (MRI) and arthroscopy to diagnose these lesions. Several early reports showed nearly 100% success in managing these lesions with arthroscopic debridement with or without acromioplasty. This series compares 32 patients with significant partial-thickness rotator cuff tears treated with debridement and acromioplasty versus 33 patients with mini-open repair. Follow-up was from 2 to 7 years. Preoperative MRI was not useful; when positive, preoperative arthrography was useful for articular side tears. Of the tears, 12% were bursal side tears and the remainder were articular side tears; all were at least 50% or more of the thickness of the tendon. A significant number of the arthroscopic group had fair results by UCLA score criteria. Three patients reruptured the remaining cuff later despite adequate acromioplasty. Healing of the partial tear was never observed at second-look arthroscopy. Although postoperative pain was significantly greater and recovery slower with open repair, no patient was reoperated on and rerupture of the repair did not occur. The outstanding results of prior studies of cuff debridement were not duplicated in this series of cuff debridements with long-term follow-up. Adequate acromioplasty alone does not prophylactically prevent rotator cuff tear progression. Recognition and repair of these significant partial tears may be advisable for the long-term function of the shoulder despite short-term improvement in morbidity with arthroscopic treatment.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 2 (March), 1999: pp 126–131

The Measurement of Subacromial Contact Pressure in Patients With Impingement Syndrome

Summary: 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 × 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°, 90°, and 180°, 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° and <.001 in all other positions). At 90° 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.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 2 (March), 1999: pp 121–125

A Multicenter Study of 210 Rotator Cuff Tears Treated by Arthroscopic Acromioplasty

Summary: We followed 210 cases of rotator cuff tears treated in four French centers by arthroscopic acromioplasty in 195 cases and by a tenotomy of the Long Head of Biceps (LHB) in 15 cases. All patients were evaluated by means of the Constant score (CS) and radiographic imaging. The mean age was 61 years and the mean follow-up period was 26.6 months (range, 12 to 93 months). The preoperative CS was 38.2 points; 41% were supraspinatus tears, 40.2% were supra and infraspinatus tears, 10.5% were three-tendon tears, and 8.1% were supraspinatus and subscapularis tears. The LHB was altered or disrupted in 77% of cases, dislocated or subluxated in 44% of cases. Acromioplasty was associated to tear debridement in 183 cases (88%) and to a tenotomy of the LHB in 38 cases (19%) of which 15 did not benefit from an associated acromioplasty. Global objective results shown by the corrected CS reached 79.7% and were satisfying in 73% of cases. Poor clinical factors were preoperative shoulder stiffness, postoperative painful crises, worker compensation, a preoperative history longer than 4 years, and young age. The poor anatomic factors were osteoarthritis, a lesion of the acromioclavicular joint or of the LHB tendon. An isolated supraspinatus tear will produce much better results than a triple-tendon tear. The persistence of an aggressive acromion was a prejudicial factor. The benefits of LHB tenotomy were evident and could be isolated in case of massive rotator tears. It seems that LHB tenotomy was particularly effective for massive tears of two or more tendons. Arthroscopic acromioplasty is an excellent indication for elderly patients without professional activity, functionally less demanding that a younger patient.0749-8063/99/1501-1797$3.00/0

Impingement syndrome following total shoulder arthroplasty and humeral hemiarthroplasty: treatment with arthroscopic acromioplasty

Pain following total shoulder arthroplasty or humeral hemiarthroplasty is uncommon. Impingement syndrome can be an infrequent source of pain following shoulder arthroplasty. We retrospectively reviewed six patients with refractory impingement syndrome treated with arthroscopic acromioplasty following either total shoulder arthroplasty (four patients) or humeral hemiarthroplasty (two patients). Chronic impingement syndrome requiring acromioplasty affected 3% of all patients who underwent total shoulder arthroplasty or humeral hemiarthroplasty during the study period. A thorough history, physical examination, and radiographic findings made the clinical diagnosis of impingement syndrome. All six patients had positive impingement signs and a positive impingement test with subacromial lidocaine injection. Preoperative radiographs revealed a type II or III acromion and subacromial outlet narrowing in five of six patients. Other sources of shoulder pain including prosthesis loosening, infection, and rotator cuff tear were ruled out preoperatively by physical examination and radiographic findings, and were confirmed by arthroscopic examination. The results of arthroscopic acromioplasty were a reduction in pain from 7.5 preoperatively to 1.6 postoperatively, on a scale from 0 to 10. Five of six patients were completely satisfied with the results of their arthroscopic surgery. Overall, according to the University of California at Los Angeles end-result score, the results were rated as excellent or good in five patients, and unsatisfactory in one patient. Arthroscopic acromioplasty can be a successful technique for the treatment of chronic impingement syndrome following total shoulder arthroplasty or hemiarthroplasty in appropriate patients.Arthroscopy 1998 Oct;14(7):665-70

Arthroscopic acromioplasty: a 6- to 10-year follow-up

Arthroscopic acromioplasty has become a common procedure for the treatment of chronic impingement syndrome. Short-term studies have consistently shown good results; however, long-term data have not previously been reported in the literature. Of 102 consecutive patients undergoing arthroscopic acromioplasty at our institution from 1984 to 1988, 82 patients (83 shoulders) were available for evaluation. The patients were reviewed after a mean of 8 years, 5 months from their original surgery. There were 16 failures (19%) with unsatisfactory results following surgery; 13 patients (15%) required further surgery to relieve persistent pain. Thirty-three percent of all patients previously involved in sports were unable to return to overhead and throwing sports due to pain and lack of power with throwing. Overall, 81% of patients in our series had good to excellent results after 6 to 10 years. To optimize the indications for the procedure, other causes of impingement, such as occult instability and degenerative joint disease, should be ruled out. Throwers may have difficulty returning to their sport at the same level of intensity, and should be addressed independently. Arthroscopy 1998 May-Jun;14(4):382-8

The deltoid muscle origin. Histologic characteristics and effects of subacromial decompression.

The histologic characteristics of the deltoid muscle attachment to nine cadaveric acromia were studied using light microscopy. The deltoid muscle attaches to the anterior and lateral acromion primarily by direct tendinous attachment. The muscle attaches to the dorsal side of the acromion by periosteal fiber attachment. In the specimens studied, a hypothetical acromioplasty of 4 mm would release, on average, 41% of the direct fiber attachment, and a 6-mm acromioplasty would release 69% for all zones examined histologically. The functional and clinical effects of these findings are not known, but the deltoid muscle would be released by arthroscopic acromioplasty in areas where bone is removed.

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<h3>Objective:</h3> To evaluate the rate of absenteeism from work in patients who had undergone open or arthroscopic acromioplasty. <h3>Design:</h3> A retrospective case series. <h3>Setting:</h3> A university hospital. <h3>Patients:</h3> Eighteen patients...

The effects of arthroscopic acromioplasty on the acromioclavicular joint

Thirty patients with 31 shoulders underwent clinical and radiologic evaluation 5 to 6 years after arthroscopic acromioplasty. The mean age was 51 years. The acromioclavicular (AC) joint was assessed for tenderness on palpation and pain on horizontal adduction of the shoulder. All patients underwent a radiologic examination consisting of an anteroposterior view of the AC joint and bilateral stress views. No patient had superior translation or widening of more than 1 mm of the AC joint on stress views on the unoperated side. On the operated side 12 (38%) shoulders showed signs of instability consisting of a superior translation of the clavicle of 2 to 3 mm, distraction on weight bearing view, or both. No severely osteoarthritic AC joint (grade 3 or 4) was unstable. The degree of osteoarthritis did not differ for both shoulders, suggesting that arthroscopic acromioplasty does not accelerate osteoarthritic change in the AC joint but can induce instability. Nine patients had tenderness over the AC joint and instability on stress views. They had a significantly reduced University of California Los Angeles score of 25 ± 5 compared with the other patients (29.5 ± 7). We conclude that preservation of the inferior capsule during arthroscopic acromioplasty is important for the integrity of the AC joint in patients without severe osteoarthritic changes.

Arthroscopic surgical measures in the shoulder joint

Arthroscopic and open surgery have to be combined for successful surgical therapy of the shoulder joint. A surgeon performing open surgery alone or just using arthroscopic measures cannot cover the full spectrum of modern shoulder surgery. Isolated diagnostic arthroscopy is rarely indicated. Far more common, diagnostic arthroscopy is combined with an operative procedure both to confirm preoperative assessment of pathology and to uncover associated lesions. The results of arthroscopic stabilization of chronic anterior post-traumatic dislocations fail to compare with the high success rates of open procedures. Better patient selection will probably be the key to improving results. In cases of acute traumatic first-time dislocation in young, highly athletic people, arthroscopic repair of the isolated Bankart-Perthes lesion offers the attractive advantage of anatomic reconstruction with minimal soft-tissue dissection. Further indications for arthroscopic measurements of pathologies of the glenohumeral joint are synovectomy in rheumatoid arthritis, capsulotomy in frozen shoulder and tenodesis for lesions of the long head of the biceps. Arthroscopic subacromial decompression according to Ellman is the procedure performed most often and most successfully in the shoulder joint and has overcome the classic Neer open acromioplasty. For smaller tears of the supraspinatus tendon, arthroscopic acromioplasty can be combined with an all arthroscopic suture repair or with mini-open repair. Larger tears of the rotator cuff are still the domain for open reconstructive procedures. In associated or isolated AC joint arthritis, an arthroscopic Mumford procedure can be performed. For chronic calcific tendinitis, isolated arthroscopic excision of the calcium deposit is of great value. Additionally, acromioplasty is needed for true mechanical obstruction of the subacromial space.

Arthroscopic release of postoperative capsular contracture of the shoulder.

A loss of motion after an operation on the shoulder often cannot be treated successfully with physical therapy or closed manipulation. Although open release techniques generally improve motion, they involve extensive dissection. We developed a technique of arthroscopic capsular release and applied it in eighteen patients who had postoperative stiffness of the shoulder. The patients were selected for the arthroscopic release technique if a conservative program of physical therapy and an attempted closed manipulation had failed to restore motion and if they had no known extra-articular contractures. Five of the thirteen patients who had had a global loss of shoulder motion had motion restored with the anterior capsular release, and six needed an additional release of the posterior aspect of the capsule--that is, a combined (anterior and posterior) capsular release. The arthroscopic procedure could not be completed in the remaining two patients because of an extra-articular scar involving the subscapularis, but those patients were managed successfully with an open release. As five patients had lost only internal rotation and flexion, they had only a posterior capsular release. For the eleven patients who had had either an anterior or a combined (anterior and posterior) capsular release, the mean improvement in the score of Constant and Murley was 43 points (range, 31 to 62 points) and all improvements in motion were significant (p < 0.01). Flexion improved a mean of 51 degrees (range, 10 to 65 degrees); external rotation in adduction and abduction, 31 degrees (range, 10 to 50 degrees) and 40 degrees (range, 5 to 80 degrees), respectively; and internal rotation in adduction and abduction, six spinous-process levels (range, three to eleven levels) and 41 degrees (range, 20 to 70 degrees), respectively. For the five patients who had an isolated posterior capsular release, the score of Constant and Murley improved a mean of 20 points (range, 5 to 35 points) and the improvements in motion also were significant (p < 0.05 and 0.005). Internal rotation in adduction and abduction improved a mean of four spinous-process levels (range, one to ten levels) and 42 degrees (range, 30 to 60 degrees), respectively. Eight patients had an arthroscopic acromioplasty for concomitant impingement disease. One patient who had had a combined (anterior and posterior) release and one who had had a posterior capsular release continued to have pain because of injury of the articular cartilage from a previous operation. We concluded that arthroscopic capsular release is a reliable method for restoring motion with minimum morbidity in carefully selected patients who have postoperative stiffness of the shoulder. When necessary, it can be converted to an open release.

THE ANATOMY OF THE ANTERIOR ORIGIN OF THE DELTOID

We studied the origin of the anterior deltoid from the lateral third of the clavicle and the leading anterior edge of the acromion in 18 cadaver shoulders by anatomical and histological methods. The main origin of the deltoid was from the superior surface of the anterior acromion, but muscle and tendinous attachments were also seen on the entire anterior surface of the acromion, its anteroinferior surface and on the whole width of the anterior surface of the clavicle. Mock arthroscopic acromioplasty was shown to detach deltoid fibres from the anterior surfaces, leaving the superior attachment in continuity. Potentially, arthroscopic subacromial and clavicular resection can detach deltoid fibres originating from the anterior and anteroinferior surfaces of the acromion and clavicle and thus weaken the anterior deltoid.

The anatomy of the anterior origin of the deltoid.

We studied the origin of the anterior deltoid from the lateral third of the clavicle and the leading anterior edge of the acromion in 18 cadaver shoulders by anatomical and histological methods. The main origin of the deltoid was from the superior surface of the anterior acromion, but muscle and tendinous attachments were also seen on the entire anterior surface of the acromion, its anteroinferior surface and on the whole width of the anterior surface of the clavicle. Mock arthroscopic acromioplasty was shown to detach deltoid fibres from the anterior surfaces, leaving the superior attachment in continuity. Potentially, arthroscopic subacromial and clavicular resection can detach deltoid fibres originating from the anterior and anteroinferior surfaces of the acromion and clavicle and thus weaken the anterior deltoid.

ARTHROSCOPIC ACROMIOPLASTY: Current Status

Impingment is a chronic syndrome characterized by microtrauma, which causes progressive injury to the rotator cuff tendon. In recent years, arthro- scopic subacromial decompression/acromioplasty has been frequently used for the treatment of impingement syndrome and is quickly becoming the preferred surgical treatment when conservative modalities fail. Arthroscopic acromioplasty offers many benefits over open acromioplasty, including better cosmesis, lessened preoperative morbidity, a more complete intraoperative examination, and a hastened, early rehabilitation program.

Arthroscopic therapy of tendinitis calcarea--acromioplasty or removal of calcium?

In a retrospective analysis we evaluated 48 patients who had been arthroscopically treated for tendinitis calcarea. The calcific deposit was removed whenever possible and all patients were treated by arthroscopic subacromial decompression. In subjects who showed subacromial stenosis by X-ray or by intraoperative findings, an arthroscopic acromioplasty was performed. At follow-up all patients were evaluated according to the Constant score. Additionally all pre- and postoperative X-rays were reviewed. After surgery the Constant score significantly improved. In all cases where acromioplasty was performed, a flattening of the bony configuration was achieved. The X-ray analysis showed that no calcific deposit with blurred borders converted to sharp borders. There was also no deposit that converted from a transparent appearance to a dense structure. Patients with disappearance of the calcific deposit post-operatively had significantly better outcome than patients with no change in the X-ray. An additional acromioplasty did not improve the results. The aim of arthroscopic treatment of calcific tendinitis has to be the removal of the calcific deposit. Acromioplasty does not lead to further improvement to the result.

Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder.

Idiopathic adhesive capsulitis usually responds to gentle physical therapy or, if that fails, to closed manipulation with the patient under anesthesia. In some patients, however, loss of motion may be refractory to either of these treatments and an operative release may be indicated. We are reporting on the technique and results of arthroscopic capsular release as a new alternative for the management of such patients. During a three-year period, we managed twenty-three patients who had idiopathic adhesive capsulitis that had failed to respond to physical therapy or closed manipulation. These patients had an arthroscopic anterior capsular release and received forty-eight hours of intensive physical therapy as inpatients. During the physical therapy, the patients received an interscalene regional analgesic with use of repeated nerve blocks or with a continuous infusion through an interscalene catheter. This was followed by a supervised outpatient physical-therapy program. Six patients also had an arthroscopic acromioplasty for the treatment of impingement. There were no complications related to any of the procedures. At a mean of thirty-nine months (range, twenty-four to sixty-four months) after the arthroscopic procedure, the improvement in the score of Constant and Murley averaged 48 points (range, 13 to 77 points). The mean improvement in motion was 49 degrees (range, 0 to 105 degrees) for flexion; 42 degrees (range, 10 to 80 degrees) and 53 degrees (range, 0 to 100 degrees) for external rotation in adduction and abduction, respectively; and eight spinous-process levels (range, three to fourteen levels) and 33 degrees (range, 30 to 60 degrees) for internal rotation in adduction and abduction, respectively. These gains in motion were all significant (p < 0.01) compared with the preoperative values and were within a mean of 7 degrees of the values for the contralateral, normal shoulder. We concluded that, in patients who have loss of motion that is refractory to closed manipulation, arthroscopic capsular release improves motion reliably with little operative morbidity.