Arthroscopic Acromioplasty: Discussion and Outcomes:

Discussion:
    - objective good to excellent results may be achieved in over 70% of patients, and subjective satisfactory results are achieved in over 90% of patients;
    - shoulder arthroscopy is indicated in cases of impingement syndrome and questionable rotator cuff tear repair, since the shoulder scope will be able to determine the status of the cuff, and an arthroscopic acromioplasty can be performed if a cuff tear is not present;
    - indications:
           - young athletic patient w/ stage II impingement and strong desire to return to spots;
                   - as reported by Tibone, et al (1985), only 43% of 33 patients were able to return to sports after open acromioplasty;
                   - in contrast, Altchek, et al (1990), reported that 76% of 33 atheletically inclined patients were able to return to sports;
                          - the patients that were unable to return to sports, usually had inferior labral pathology, indicating occult instability;
                          - average recovery time is 4 months;
                   - cautions: beware that impingement in younger patients may be due to occult anterior instability;
                   - Shoulder impingement syndrome in athletes treated by an anterior acromioplasty.
                   - Arthroscopic acromioplasty. Technique and results.
          - older patient w/ impingement and massive rotator cuff tear;
                   - in these patients, the goal should be relief of pain and not improvement in function (under the assumption that the cuff tear cannot be repaired);
                   - this subgroup of patients is also more likely to have degenerative lesions in other joints, which makes a quick rehabilitation essential (e.g., DJD of the contralateral hip would make use of a cane difficult);
    - relative contra-indications:
          - young to middle aged adult w/ significant weakness due to mid-sized (1-3 cm) rotator cuff tear, in which case an open acromioplasty might be more appropriate;
          - type III acromion:
                 - as Rockwood as pointed out, acromioplasty (either open or arthroscopic) necessitates that the inferior and anterior attachments of the deltoid to the acromion must be released, leaving only the superior deltoid as an attachment;
                        - w/ a type III acromion, the deltoid stripping may especially large, and therefore the surgeon should consider open acromionplasty with reattachment of the deltoid to the anterior aspect of the acromial edge;
          - os acromiale:
                 - may instead require open reduction and internal fixation and decompression;
          - internal rotation contracture:
                 - limitation of external rotation worsens impingement syndrome since the greater tuberosity cannot clear the acromion as the arm is elevated;
                 - logically, by improving the internal rotation contracture, the impingement syndrome will be relieved;
          - greater tuberosity osteophyte:
                 - if radiographs reveal a prominent greater tuberosity osteophyte (which is often co-existent w/ rotator cuff tear), then removal of the osteophyte is carried out by open means;
    - outcomes:
           - in the study by Spangehl, et al, authors evaluated whether arthroscopic acromioplasty is equivalent or superior to open acromioplasty:
                 - 71 patients with a clinical diagnosis of impingement syndrome were randomized to arthroscopic or open acromioplasty;
                 - 9 were excluded because of full-thickness rotator cuff tears diagnosed after randomization;
                 - there was no significant difference between open and arthroscopic acromioplasty in visual analog scales for postoperative improvement (P = .30), patient satisfaction (P = .94),
                         open was superior to arthroscopic acromioplasty for pain and function (P = .01).
                 - 67% of patients had a good or excellent result - this increased to 87% when unsettled compensation claims were excluded;
                 - Arthroscopic versus open acromioplasty: A prospective, randomized, blinded study

http://www.wheelessonline.com/ Duke Orthopaedics