Aims

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.

The February 2014 Shoulder & Elbow Roundup. 360 . looks at: whether arthroscopic acromioplasty is a cost-effective intervention; shockwave therapy in cuff tear; whether microfracture relieves short-term pain in cuff repair; the promising early results from L-PRF augmented cuff repairs; rehabilitation following cuff repair; supination strength following biceps tendon rupture; whether longer is better in humeral components; fatty degeneration in a rodent model; and the controversial acromioclavicular joint dislocation

We have compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173 patients) with supraspinatus tendon tears were randomly allocated into one of three groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2) and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was assessed and followed up by an independent observer pre-operatively and at three, six and twelve months after the intervention.

Of these, 167 shoulders were available for assessment at one year (follow-up rate of 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65 years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55 shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no between-group differences in the Constant score at final follow-up: 74.1 (sd 14.2), 77.2 (sd 13.0) and 77.9 (sd 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34). These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.

Cite this article: Bone Joint J 2014;96-B:75–81.

Objectives. To report the five-year results of a randomised controlled trial examining the effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. Methods. A total of 140 patients were randomly divided into two groups: 1) supervised exercise programme (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). Results. The main outcome measure was self-reported pain as measured on a visual analogue scale. At the five-year assessment a total of 109 patients were examined (52 in the exercise group and 57 in the combined treatment group). There was a significant decrease in mean self-reported pain on the VAS between baseline and the five-year follow-up in both the exercise group (from 6.5 (1 to 10) to 2.2 (0 to 8); p < 0.001) and the combined treatment group (from 6.4 (2 to 10) to 1.9 (0 to 8); p < 0.001). The same trend was seen in the secondary outcome measures (disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days). An intention-to-treat analysis showed statistically significant improvements in both groups at five years compared with baseline. Further, improvement continued between the two- and five-year timepoints. No statistically significant differences were found in the patient-centred primary and secondary parameters between the two treatment groups. Conclusions. Differences in the patient-centred primary and secondary parameters between the two treatment groups were not statistically significant, suggesting that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment.

Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p − 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8°, p = 0.003) and for reduction in pain (difference on a visual analogue scale −1.7 cm, p < 0.0005).

We report a randomised controlled trial to examine 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 provides 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. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven

The purpose of this prospective randomised clinical trial is to examine the effect of acromioplasty on the outcome of arthroscopic rotator cuff repair. Patients included individuals that were referred for assessment after six months of failed conservative management. Following informed consent patients were randomly assigned to receive arthroscopic rotator cuff repair with or without acromioplasty. The surgeon was not blinded to the type of procedure; however, the researcher who performed the follow-up evaluations and the patient was blinded to the surgical protocol. Subacromial decompression (acromioplasty) was performed with release of the coracoacromial ligament off the anterior undersurface of the acromion. The procedure for arthroscopic cuff repair without acromioplasty followed the protocol of arthroscopic cuff repair with acromioplasty, without division of the coracoacromial ligament or resection of the acromion. Both groups experienced the same post-operative rehabilitation protocol. Wound healing and active and passive range of motion were assessed and recorded at six to eight weeks post-operatively. Subsequent post-operative visits occurred at three, six, twelve, eighteen and twenty-four months and included documentation of patient range of motion, patient derived WORC scores (1) and complete ASES scores. Preliminary results suggest, based on a one-tailed t-test, patients that receive a rotator cuff repair with acromioplasty demonstrate a statistically significant improvement (< 0.05) in Quality of Life, based on WORC and ASES scores, compared to the non-acromioplasty group. To date, three patients in the non-acromioplasty group required a revision surgery; two of these patients had a Type III acromion. Arthroscopic rotator cuff repair with arthroscopic acromioplasty in the treatment of full thickness rotator cuff tears is recommended for patients with a Type III acromion

In a prospective randomised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty. A total of 57 patients with a mean age of 47 years (31 to 60) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial. The type of acromion was classified according to Bigliani. Patients were assessed at follow-up using the Constant score, the simple shoulder test and visual analogue scores for pain and functional impairment. One patient was lost to follow-up.

At a mean follow-up of 2.5 years (1 to 5) both bursectomy and acromioplasty gave good clinical results. No statistically significant differences were found between the two treatments. The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment. As a result, we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder.

Purpose: Failure is still observed after 20% of acromioplasties which can be explained by acromioclavicular osteoarthritis. The purpose of this study was to demonstrate the deleterious effect of this degeneration on outcome. Material and methods: We reviewed 103 arthroscopic acromioplasties performed in 100 patients who presented non-torn non-calcified tenopathies. Seven patients were excluded so 96 patients, 63 women and 33 men were retained for analysis. Mean age at operation was 48.2 years and mean follow-up was 3.8 years. Patients were divided into two groups on the basis of the sonographic findings: group 1 had no computed tomography (CT) signs of acromioclavicular osteoarthritis (66 patients), such signs were found in group 2 (30 patients). Each patient was reviewed clinically and CT-scan was used to diagnosis osteoarthritis classed as stage 0 to 3. Subjective outcome was assessed in terms of patient satisfaction and objectively with the Constant score. Results: Subjectively, three-quarters of the patients in group 1 were satisfied versus one-third in group 2. The Constant score confirmed this finding with a mean 76 points in group 1 versus 68 in group 2 (the weighted score was 93.5% and 83% respectively). The weighted score showed that good or excellent results were achieved in 84.84% of the patients in group 1 and in 43% in group 2. Discussion: Our results are in agreement with data in the literature and provide scientific evidence of the influence of acromioclavicular osteoarthritis on the failure of acromioplasty. The results in group 1 were clearly better than in group 2, proving statistically a widely accepted notion: acromioclavicular osteoarthritis compromises significantly outcome of acromioplasty. Furthermore, it is interesting to note that among the seven cases excluded (for resection of the articulation), six had satisfactory outcomes. Conclusion: These results confirm the unfavourable influence of acromioclavicular osteoarthritis on the outcome of acromioplasty. A prospective study designed to determine the effect of simultaneous acromioclavicular resection would be useful to propose a coherent therapeutic approach

Purpose: The purpose of this study was to assess long-term functional outcome after arthroscopic acromioplasty for full-thickness rotator cuff tears, to evaluate the efficacy of complementary procedures (biceps tenotomy, extended acromioclavicular resection), and to examine the course of anatomic lesions. Material and methods: From 1988 to 1994, 141 full-thickness rotator cuff tears were treated by arthroscopic acromioplasty. Ninety-eight patients, mean age 60 years, were reviewed clinically, radiographically, and sonographically at more than eight years. The mean preoperative Constant score was 48.5 points. The tear involved the supraspinatus in 18 cases, the supraspinatus and infraspinatus in 40, the supraspinatus and the subscapularis in ten, and all three tendons in 20. Coronal extension showed a distal tear in four, an intermediate tear in 52, and a retracted stump in 32. Systemic acromioplasty was associated in 36 patients with tenotomy of the long head of the brachial biceps and in 44 with acromioclavicular extension. Results: At mean follow-up of 10.7 years (8–13.5), the mean Constant score was 60 points. The clinical outcome was excellent or good in 39.7%, fair in 45.5%, and poor in 14.8. 62.5% of the patients were satisfied or very satisfied. The height of the subacromial space was 5.19 mm at last follow-up compared with 4.3 mm preoperatively. The antalgesic effect of biceps tenotomy was significant when the initial acromiohumeral space was less than 5 mm. This procedure did not produce any significant change in the subacromial height or development of osteoarthritis at last follow-up. Sonography showed stability of the size of the tear in 83.8% of the cases. The results were significantly less satisfactory when the initial tear involved the subscapularis or all three tendons. Conclusion: The clinical results of arthroscopic acropmioplasty for full-thickness tears show long-term stability. Biceps tenotomy improves the antalgesic effect significantly, particularly if the subachromial space measures less than 5 mm preoperatively, without causing significant radiological degradation. Extension to the acromioclavicular level should be systematic in patients with acromioclavicular pain preoperatively and/or radiological anomalies

This study looks at the outcomes of 112 full thickness rotator cuff tears treated by arthroscopic decompression, without repair of the rotator cuff, from 1994. The decision not to repair the tear was taken only if four criteria were met. First, if there was no clinical weakness on manual testing of the individual rotator cuff muscles, secondly, if there was full abduction, thirdly, if there was no riding up of the humeral head on the anteroposterior radiograph and fourthly, if there was well-developed ‘cable’ on arthroscopic visualisation of the rotator cuff. The mean age of the patients, 38% of whom were men, was 62 years (47 to 83). In 44% the right shoulder was operated on. There were 32% type-II acromions and 68% type-III. There were 58% C2 tears and 42% C3 tears. All had arthroscopic acromioplasty and acromioclavicular joint excision. Later, three required an open acromioclavicular joint excision with one open cuff repair. At a mean follow-up time of 71 months (11 to 110), the clinical and surgical notes and radiographs were reviewed and a modified Simple Shoulder Test (SST) used to evaluate outcomes by telephone. The mean postoperative SST was 11.5 out of 12 (3 to 12). Complete relief was reported in 84% of cases. These subjective results suggest that, with careful selection, not all full thickness tears of the rotator cuff need repair

Purpose: To present our experience in the treatment of sub-acromial impingement by the method of arthroscopic acromioplasty. Material – Method: This study includes 41 patients (17 males and 24 females) with average age 53.07 years (range 22 – 69). All patients were suffering from intense pain in the shoulder joint and presented movement limitation. The patients were evaluated clinically and with plain Xrays and MRI of the region. Prior to the intervention all the patients had followed a variety of adequate conservative treatment including immobilization, anti-inflammatory therapy, physical therapy, local infiltration with corticoids and xylocain. The results proved unsatisfactory. The surgical technique consisted of triple portal arthhroscopic intervention (anterior, posterior, lateral) and the use of a shaver for the completion of the acromio – plasty. The surgical time was 40 minutes (30 – 55). The post – operative protocol, which included passive and active physiotherapy, was identical for all patients. Results: The required average hospitalization was 36 hours (14 – 48). The average time needed for satisfactory rehabilitation amounted to 27 days (20 – 45). We followed closely our patients for an average of 11 months. (4 – 16). The painful symptoms disappeared thoroughly in 92.7% of our cases (38). Moderate pain persisted in 7.3% (3). Shoulder movements were fully restored in 95.1% (39). We observed no peri-operative or post – operative complications. Conclusions: The arthroscopic airomioplasty is the surgical treatment of choice in the cases of sub-aromial impingement. The method presents no great technical difficulties. The operative time is considered short, and the results in their great majority are excellent. The hospitalization needed is minimal, the rehabilitation is rapid, and the economic cost is not significant. We firmly believe that the arthroscopic acromio – plasty is the treatment of choice in the case of failed conservative treatment

Arthroscopic acromioplasty is said to be a difficult procedure to learn although Gartsman stated that most surgeons can reliably perform an arthroscopic decompression after instruction in 10–20 cases. We assessed the learning curve for one consultant surgeon.Patients were selected on the basis of clinical examination and all had signs of impingement at arthroscopy. Surgery was performed between February 1993 and June 1996. Patients with full thickness tears were excluded from the study. The senior author had not performed any arthroscopic acromioplasties prior to providing a service in this hospital. Each shoulder was assessed immediately prior to surgery and at follow up using the Constant and Murley method of functional assessment without the power component. Patients were asked if they would have the operation again, with the benefit of hindsight.Of 89 shoulders complete preoperative and postoperative scoring beyond 6 months was available in 71. Of these, 62 operations were performed by one consultant (ANS) and 9 by trainees under his guidance. Patient questionnaires were completed for 73 of 89 shoulders. A standard operative technique under general anaesthesia was used for all patients. The overall improvement in shoulder function was 10.3 (SD 12.4) points (p< 0.0001). The change in shoulder score did not vary with increasing surgical experience. The length of operation, however, shortened with increasing experience with a mean of 106 minutes and 60 minutes for the first and last five operations. Questionnaire analysis found 82% would have the operation again. In our study operative time reached a plateau after approximately the first twenty five cases but the results of these early operations are good

Introduction: The advantages of arthroscopically assisted mini-open rotator cuff repairs have supported the evolution of all arthroscopic rotator cuff repairs. Careful analysis of these complex techniques is required to ensure that excellent or good surgical outcomes are achieved. Methods: In each case a diagnostic arthroscopy preceded the repair. The configuration of the tear was noted and an assessment of the ease of repair was made. An arthroscopic acromioplasty was performed in all cases. Soft tissue releases were carried out. Bone and cuff preparation was required. The principles of margin convergence and balancing of force couples of the rotator cuff without tension mismatch were followed. Knot and loop security was required for cuff fixation. All patients who underwent arthroscopic rotator cuff repair from 1997 to 2001 were reviewed. Outcome scores were evaluated for pain, levels of activity, range of motion and strength. Conclusions: Results comparable to mini-open repairs can be achieved. Complex arthroscopic skills must be mastered and the attraction of cosmesis and lower perioperative morbidity and stiffness must not compromise the long-term outcomes of the surgery

Purpose: There is still debate on classification, pathogenesis, and treatment of partial non-full thickness tears of the rotator cuff. We assessed mid-term outcome after arthroscopic repair. Material and methods: Between 1990 and 1998, 208 partial tears of the rotator cuffs were treated in our unit. Eighty patients were reviewed by an examiner different and independent from the surgery team. The review included a physical examination, Constant score and radiography. The series included 42 men and 38 women, mean age 52 years (23–73) who were seen at a mean follow-up of 59 months (17–118). We identified four groups: group 1 included lesions of the deep articular aspect of the supraspinatus: 34 cases; group 2 included tears of the superficial aspect: 27 cases; group 3 included tears involving both the deep and superficial aspect without full-thickness tear on the preoperative arthrogram; and group 4 included lesions involving a partial tear of the supraspinatus associated with another articular lesion. Acromioplasty was performed in all cases associated with section of the acromiocoracoid ligament. Results: Absolute Constant score progressed from 53 points preoperatively to 80 points at last follow-up. Mean Constant score of the contralateral shoulder was 87 points. There was a significant difference between outcome in the first three groups where the mean age was 50 years and the fourth group (trauma context) where the mean age was 36 years. Constant score was 84.7, 92, 92, and 73 for groups 1, 2, 3 and 4 respectively. There was no statistically significant improvement compared with the preoperative Constant score (67 points). Radiographically, there was no change in the subacromial space. Superficial lesions were more frequently associated with type 3 acromial impingement. Discussion: Globally, we observed a deterioration of outcome with time compared with the first review, with 76% satisfactory results at five years. The same outcome was obtained with superficial and deep lesions. We are in agreement with others that it is necessary to identify a subgroup of patients under 40 years of age with a partial tear of the rotator cuff in a trauma context. For these patients, arthroscopic acromioplasty is not a satisfactory therapeutic approach. The causal lesion (posterosuperior impingement, rim injury or instability) should be treated

Purpose: Several treatments can be proposed for calcified tenopathy of the rotator cuff. Corticosteroid infiltration, radioscopic trituration-aspiration, and arthroscopy are the most widely used modalities. Over the last decade, we have come to refer our cases of well-circumscribed calcified tenopathy easily accessible to radioscopy to our radiology colleagues since radioscopic treatment has appeared to be quite cost-effective. This trend has continued despite the new interest of the arthroscopists in this disease. We have nevertheless had a certain number of failures (25%) and at this time have decided to prefer arthroscopy. The purpose of this work was to present our results with arthroscopy used after failure of tirturation-aspiration or for patients with calcifications we considered to have contraindications for trituration-aspiration (poorly circumscribed chain of calcifications). Material and methods: Between 1990 and 1997, we performed 28 arthroscopic procedures in 28 patients. There were 18 women and ten men, mean age 47.5 years (28–71 years). All suffered pain at night and painful blockage during certain motions, particularly anterolateal elevation and forced internal rotation. We did not use the preoperative Constant score because we considered that the pain always gives a false score in these patients, particularly for muscle force. Nevertheless, the mean pain score preoperatively was 4.5 (0–10), daily activity was 14 (8–18) and active motion was 32 (20–40). All calcifications were located in the supraspinatus and the anterior part of the infraspinatus. Acromial morphology was type III in seven cases. All the patients underwent arthroscopy with resection of the coracoacromial ligament and anterior acromioplasty without touching the residual calcification. Results: All patients were reviewed by an independent surgeon different than the operator. Mean follow-up was 54 months (18–108 months). Subjectively, 89% of the patients were cured or improved, 11% were unchanged. Objectively, the Constant score weighted for age and sex was a mean 91.4% (50–100%) with a median 100%. We had 20 shoulders with excellent outcome (weighted Constant score 85–94%), two with fair outcome (65–84%), and three with poor outcome (< 65%), giving 82% satisfactory outcome. Muscle force was very satisfactory (mean 7.5%) and close to the contralateral shoulder (8.25 kg). Radiologically, 17 of the 29 shoulders were cleared of calcifications (61%). Conclusion: Arthroscopic acromioplasty after failure of trituration-aspiration gives quite satisfactory results, including for calcifications we had considered to by “untriturables”

The acromion is a bony process that juts out from the lateral end of the scapular spine. It is continuous with the blade and the spinous process. The process is rectangular, and carries a facet for the clavicle. Inferiorly is sited the subacromial bursa. Inferior encroachment or displacement of the acromion can result in impingement.

The aim of this osteological study was to assess the presence of acromial displacement and variations predisposing to compaction of the subacromial space. Using the method described by Morrison and Bigliana, we assessed the scapulae of 128 men and women ranging from 35 to 92 years of age. We found a flat acromion in 30%, no hook in 48%, a small hook in 18% and a large hook in 4%. The presence of a hook was associated with a subacromial facet and a large hook with glenoid erosion.

This study confirms the presence of four types of acromion.

Purpose: Arthroscopic arthroplasty for painful shoulder is not always successful. Repeated arthroscopy is sometimes discussed for patients with recurrent pain. The purpose of this work was to determine the technique and identify indications. Material and methods: We conducted a retrospective analysis of 24 patients (13 men, 11 women), mean age 52 years, who underwent repeated arthroscopy after failure within 31 months of arthroscopic acromioplasty with no other intervention. Three groups were formed: group 1 (7 patients): subacromial impingement due to tendinitis with intact supraspinatus; group 2 (11 patients): subacromial impingement secondary to cuff tear; group 3 (6 patients): calcified tendinopathy. In group 1, the acromion was type 1 in three cases, type 2 in three and type 3 in one; repeated arthroscopy included complementary acromioplasty. In group 2, all patients had complementary acromioplasty; six of them with biceps tenotomy. In group 3, the remaining calcification was removed in all patients and complementary acromioplasty in three. Results: Mean follow-up was 21 months. In group 1, outcome was satisfactory in three patients (43%), irrespective of the acromial morphology. In group 2, outcome was satisfactory in six patients (55%), including five with acromioplasty with tenotomy and only one with complementary acromioplasty alone. In group 3, outcome was satisfactory in five patients (83%); one failure was attributed to remaining calcification; acromioplasty did not influence outcome. Discussion, conclusion: The acromion should not be considered as the principal cause of failure after first acromioplasty. In this series, only 33% of the patients who had complementary acromioplasty had a good outcome at last follow-up. Biceps tenotomy in patients with rotator cuff tears and removal of the calcium deposit in patients with calcified tenopathies should be considered first

Painful conditions of the acromioclavicular (AC) joint are common in South Africa, particularly among sportsmen. These conditions are often treated by open excision of the distal end of the clavicle, but an arthroscopic procedure offers many advantages. From February 1994 to February 2000, we performed 138 procedures. The mean age of patients ({71% men and 29% women) was 29 years (19 to 53). In cases of rotator cuff impingement, arthroscopic acromioplasty was followed by clavicular excision via the subacromial route. With a normal acromion and rotator cuff the AC joint was approached through two superior AC portals, avoiding removal of the AC ligaments. In all cases a standard 3.5-mm arthroscope was placed in one portal for viewing and the mechanical shaver inserted through the other. About 7 mm to 8mm of bone was removed from the clavicle. Patients were in hospital for about a day and 87% were discharged the same day. The mean follow-up time was 34 months (2 months to 4 years). Patient satisfaction was high in 32%, fair in 60% and poor in 8%. Most patients (92%) returned to all previous sports and activities. We concluded that the arthroscopic Mumford procedure is at least as successful as its open equivalent. It can be done as an outpatient procedure and permits a rapid return to activities. Cosmesis is excellent and stability of the AC joint is preserved