How much acromial bone should be removed to decrease the critical shoulder angle? A 3D CT acromioplasty planning study

BACKGROUND

A high critical shoulder angle (CSA) is associated with rotator cuff tear (RCT) and retear rate after repair. CSA reduced to less than 33° by acromioplasty is correlated with better clinical results and healing. But up to 24% of patients retain a CSA above 35° after acromioplasty. The objective of the study was to evaluate the use of 3D when planning acromioplasty and measure acromial bone removal volume dimensions.

METHODS

Computed tomography (CT) scans from 45 patients with RCT and CSA ≥ 38° were retrospectively included. A 33° CSA cutting plane was positioned. Acromion was divided into 5 mm slices and acromial bone resection measured on each slice.

RESULTS

Intra- and inter-observer reproducibility measurements were rated strong or very strong. Patients' mean preoperative CSA was 40° (38°, 49° ± 2.3°). Measurements of acromial resection were: anteroposterior length: 32.7 mm (20, 50 ± 7.4); inferior width: 7.6 mm (4.2, 19 ± 2.9); superior width: 4.1 mm (0, 16 ± 3.0); height: 6.1 mm (1.7, 6.7 ± 1.6); and cutting angle: 74° (46, 91 ± 8.0). Maximum width of acromial resection was located 10.6 mm (5, 17.5 ± 0.6) from the acromion's anterior edge and decreased gradually moving posteriorly. Preoperative CSA was linearly correlated with width (P < 0.0001, R = 84%) and length (P = 0.0001, R = 28%) of acromioplasty; the higher the CSA, the greater the width and length.

CONCLUSIONS

3D CT reconstructions are valid for planning a CSA decreasing acromioplasty. To reduce CSA to 33°, acromioplasty must be performed anterolaterally and resection is at least 2 cm long anteroposteriorly. For higher CSAs, acromioplasty may require lateral resection over 1 cm in width and up to 5 cm in length. To decrease the CSA efficiently, acromioplasty must be adapted to patient anatomy and 3D planning could be considered.

LEVEL OF EVIDENCE

IV.

A predictive model for the critical shoulder angle based on a three-dimensional analysis of scapular angular and linear morphometrics

BACKGROUND

The purpose of this study was to define the features of scapular morphology that are associated with changes in the critical shoulder angle (CSA) by developing the best predictive model for the CSA based on multiple potential explanatory variables, using a completely 3D assessment.

METHODS

3D meshes were created from CT DICOMs using InVesalius (Vers 3.1.1, RTI [Renato Archer Information Technology Centre], Brazil) and Meshmixer (3.4.35, Autodesk Inc., San Rafael, CA). The analysis included 17 potential angular, weighted linear and area measurements. The correlation of the explanatory variables with the CSA was investigated with the Pearson's correlation coefficient. Using multivariable linear regression, the approach for predictive model-building was leave-one-out cross-validation and best subset selection.

RESULTS

Fifty-three meshes were analysed. Glenoid inclination (GI) and coronal plane angulation of the acromion (CPAA) [Pearson's r: 0.535; -0.502] correlated best with CSA. The best model (adjusted R-squared value 0.67) for CSA prediction contained 10 explanatory variables including glenoid, scapular spine and acromial factors. CPAA and GI were the most important based on their distribution, estimate of coefficients and loss in predictive power if removed.

CONCLUSIONS

The relationship between scapular morphology and CSA is more complex than the concept of it being dictated solely by GI and acromial horizontal offset and includes glenoid, scapular spine and acromial factors of which CPAA and GI are most important. A further investigation in a closely defined cohort with rotator cuff tears is required before drawing any clinical conclusions about the role of surgical modification of scapular morphology.

LEVEL OF EVIDENCE

Level 4 retrospective observational cohort study with no comparison group.

Does isolated arthroscopic anterior acromioplasty modify critical shoulder angle?

INTRODUCTION

Critical shoulder angle (CSA)>35° correlates significantly with primary rotator cuff tear and re-tear after repair. Acromial axial orientation varies between individuals. The present study aimed to assess the impact of strictly anterior acromioplasty on CSA.

HYPOTHESIS

CSA is reduced by arthroscopic anterior acromioplasty.

MATERIAL AND METHODS

A single-center retrospective study included patients receiving isolated arthroscopic acromioplasty between January 2016 and December 2017. Exclusion criteria comprised history of surgery and fracture or dislocation of the shoulder. Pre- and post-operative AP shoulder radiographs were taken. The angle subtended by a line between the inferior and superior edges of the glenoid and a line between the inferior edge of the glenoid and the most lateral point on the acromion was measured.

RESULTS

One hundred and two patients were included: mean age, 50.5±10.1 years (range, 23-82 years). Mean CSA was 34.7±4.4° (range, 26-48°) preoperatively and 31.7±3.7° (range, 23-40°) postoperatively (p<0.001). In the group with CSA >35°, the decrease was significant: 34.4±3.2° (range, 28-40°) versus 38.9±2.8° (range, 36-48°) (p<0.001), with 64% CSA <35° after isolated anterior acromioplasty.

DISCUSSION

CSA was decreased by arthroscopic acromioplasty. However, in 36% of cases with preoperative CSA >35°, CSA was not normalized.

CONCLUSION

Anterior arthroscopic acromioplasty significantly reduced CSA in the overall population, and especially in case of high CSA.

LEVEL OF EVIDENCE

IV; retrospective study.

Does the critical shoulder angle decrease after acromioplasty? A systematic review and meta-analysis

BACKGROUND

Rotator cuff tears are one of the most common shoulder injuries in the older population. This study aimed to determine whether acromioplasty reliably decreases the critical shoulder angle (CSA) and describe any associated complications.

METHODS

A systematic literature review was performed according to PRISMA guidelines using PubMed, EMBASE, Web of Science, and Cochrane Library Database. Two reviewers independently screened the titles and abstracts using prespecified criteria. Studies where the acromioplasty was performed as a surgical procedure were included. Patient characteristics and degree of CSA reduction were collected from each individual study. All statistical analyses were performed using Review Manager (RevMan) 5.4.1 software. A random-effects model was used for meta-analysis.

RESULTS

A total of 9 studies involving 1236 patients were included in the meta-analysis. The age of patients ranged from 23 to 82 years. The follow-up period ranged from 12 to 30 months. Of the 9 studies, 8 (88.9%) were retrospective, 1 (11.1%) was prospective, 5 were comparative, and 4 were case series. The mean CSA was significantly reduced from 36.1° ± 4.6° to 33.7° ± 4.2 (p < 0.05). The meta-analysis showed an overall best estimate of the mean difference in pre- and postoperative CSA equal to 2.63° (95% confidence interval: 2.15, 3.11] (p < 0.00001).

CONCLUSIONS

Acromioplasty can significantly reduce CSA, notably in cases of high preoperative CSA. In addition, the effect of lateral acromioplasty on the CSA was more significant compared to anterolateral acromioplasty. Acromioplasty was not associated with complications during the short-term follow-up.

Prevalence and Clinical Impact of Acromial Cupping after Arthroscopic Rotator Cuff Repair: Does Acromioplasty Matter?

Background

Although the effectiveness of acromioplasty is controversial, it is commonly performed during rotator cuff repair to reduce external impingement. During follow-up, osteolysis under the acromion (acromial cupping) could be observed. However, this phenomenon has been rarely addressed in the literature. The purpose of this study was to compare the prevalence and severity of acromial cupping after rotator cuff repair depending on the concomitant performance of acromioplasty and evaluate the influence of acromial cupping on clinical and radiological outcome.

Methods

This is a retrospective study involving patients who underwent arthroscopic rotator cuff repair for small-to-large full-thickness rotator cuff tears from October 2015 to March 2019 and clinical follow-up and magnetic resonance imaging at least 1 year postoperatively. A total of 110 patients were enrolled and divided into two groups depending on whether acromioplasty had been performed (group A) or not (group N). The prevalence of acromial cupping was evaluated in each group. In addition, we stratified patients according to the severity of acromial cupping to investigate its influence on healing and functional scores (visual analog scale [VAS], American Shoulder and Elbow Surgeons [ASES] score, simple shoulder test [SST], and Constant-Murley score).

Results

There were 85 patients in group A and 25 patients in group N. The prevalence of acromial cupping and acromial cysts was as follows: 36.4% (40 patients) and 6.4% (7 patients), respectively, in the total subjects; 43.5% (37/85) and 5.9% (5/85), respectively, in group A; and 12.0% (3/25) and 8.0% (2/25), respectively, in group N. The prevalence of acromial cupping was significantly different between the two groups (p = 0.012). However, functional outcomes were not significantly different between groups stratified by the severity of acromial cupping (VAS, p = 0.464; ASES score, p = 0.902; SST, p = 0.816; and Constant-Murley score, p = 0.117). The difference in healing rate was statistically insignificant between groups (p = 0.726).

Conclusions

The incidence and severity of acromial cupping were significantly greater in patients who underwent rotator cuff repair with acromioplasty. It was a relatively common phenomenon, especially after acromioplasty. However, neither the existence nor the severity of acromial cupping affected functional outcomes or healing.

WITHDRAWN: Does anterior arthroscopic acromioplasty modify critical shoulder angle?

This article has been withdrawn because we accidentally published the same article twice due to an error by the Managing editor/Elsevier. The correct version of the article has been published later in Orthop Traumatol Surg Res, 108 (2022) 103040, https://doi.org/10.1016/j.otsr.2021.103040. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal

Systematic review of the literature

INTRODUCTION

Acromioplasty is controversial. Technically, it consists in bone resection, but there is no gold-standard technique and resection is often not quantified. The aims of the present study were 1/to assess the methodological quality of studies of acromioplasty; 2/to identify reports in which acromioplasty was quantified; and 3/to assess any correlation between clinical results and resection quantity.

MATERIAL AND METHODS

A systematic literature review was performed on PRISMA criteria in the PubMed, Springer and Ovid databases, including all articles in French or English referring to acromioplasty. Articles were analyzed by 2 surgeons and those with complete procedural description were selected. 1/Methodology was assessed on 3 grades according to aim of acromioplasty, intraoperative assessment of resection, and postoperative radiologic assessment. 2/Results were extracted from articles with robust methodology and quantitative data. 3/Correlations were assessed between clinical results and resection quantity.

RESULTS

Out of the 250 articles retrieved, 94 were selected. 1/44 of these (47%) specified the aim of the acromioplasty, 53 (56%) included an intraoperative clinical assessment criterion, and 13 (14%) included postoperative radiographic assessment. Methodologic quality was insufficient in 33 articles (35%), poor in 23 (24%) and robust in 38 (40%). 2/Seven articles (7.5%) included quantitative results. 3/Three articles assessed correlation between clinical results and resection quantity, but only 1 used reproducible radiographic assessment by critical shoulder angle (CSA); this study reported a significant positive correlation between clinical results and decreased CSA.

CONCLUSION

Methodology in studies of acromioplasty was largely insufficient and resection was usually not quantified. Current data to assess the usefulness of the procedure are sparse. We advocate including a Checklist for Acromioplasty Studies in the methodology of future studies. There is at present no gold-standard for assessing and quantifying acromial resection. CSA seems contributive, but other methods might be worth developing.

LEVEL OF EVIDENCE

IV; systematic review of level 1-4 studies.

Usefulness of computed tomography based three-dimensional reconstructions to assess the critical shoulder angle

BACKGROUND

The critical shoulder angle (CSA) is a radiographic measurement that provides an assessment of both glenoid inclination and acromial length. Higher values may correlate with the presence of rotator cuff tears. However, it is difficult to obtain a high-quality true anteroposterior (AP) radiograph of the shoulder, with any excess scapular version or flexion/extension resulting in deviation from the true CSA value. Three-dimensional (3D) bony reconstructions of computed tomography (CT) shoulder scans may be able to be rotated to obtain a similar view to that of true AP radiographs.

AIM

To compare CSA measurements performed on 3D bony CT reconstructions, with those on corresponding true AP radiographs.

METHODS

CT shoulder scans were matched with true AP radiographs that were classified as either Suter-Henninger type A or C quality. 3D bony reconstructions were segmented from the CT scans, and rotated to replicate an ideal true AP view. Two observers performed CSA measurements using both CT and radiographic images. Measurements were repeated after a one week interval. Reliability was assessed using intraclass correlation coefficients (ICCs) and Bland-Altman plots [bias, limits of agreement (LOA)].

RESULTS

Twenty CT shoulder scans were matched. The mean CSA values were 32.55° (± 4.26°) with radiographs and 29.82° (± 3.49°) with the CT-based method [mean difference 2.73° (± 2.86°); P < 0.001; bias +2.73°; LOA -2.17° to +7.63°]. There was a strong correlation between the two methods (r = 0.748; P < 0.001). Intra-observer reliability was similar, but the best intra-observer values were achieved by the most experienced observer using the CT-based method [ICC: 0.983 (0.958-0.993); bias +0.03°, LOA -1.28° to +1.34°]. Inter-observer reliability was better with the CT-based method [ICC: 0.897 (0.758-0.958), bias +0.24°, LOA -2.93° to +3.41°].

CONCLUSION

The described CT-based method may be a suitable alternative for critical shoulder angle measurement, as it overcomes the difficulty in obtaining a true AP radiographic view.

Assessment of postoperative acromial and subacromial morphology after arthroscopic acromioplasty using magnetic resonance imaging

OBJECTIVE

To identify the morphological characteristics of the acromion and subacromial bursal space after arthroscopic acromioplasty using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

One hundred patients who received arthroscopic rotator cuff repair and acromioplasty each received at least three MRI examinations (preoperative, first immediate postoperative, and second follow-up imaging between 8 months and 1 year postoperatively). Changes over time in the thickness and morphology of the postoperative acromion as well as the subacromial bursal space were assessed. Clinical and radiological parameters were also analyzed to identify any association with changes in acromial morphology.

RESULTS

Despite minimal acromial thinning observed at the first immediate postoperative state, the acromions showed significant thinning at the second postoperative MRI, with a mean reduction of 32%. Along with acromial thinning, an exaggerated concave contour of the acromial undersurface was observed in some patients. In the subacromial space, a loculated fluid collection developed in 91% of the patients at the second postoperative follow-up. No statistically significant association was noted between postoperative acromial thickness change and clinical or radiological factors (P value > 0.05).

CONCLUSION

A significant delayed reduction in acromial thickness within approximately 1 year of arthroscopic acromioplasty is thought to be a normal postoperative feature. The simultaneous collection of a loculated, cyst-like fluid in the subacromial bursal space may be an important associated factor of postoperative acromial thinning.

Effect of arthroscopic acromioplasty on reducing critical shoulder angle: a protocol for a prospective randomized clinical trial

Background

The critical shoulder angle (CSA), which helps to predict patients who are at risk of rotator cuff tears (RCTs) with large degree and who are susceptible to osteoarthritis with low angle, has been identified as one of the most vital acromial parameters; anterolateral and lateral acromioplasties have been proven to be valid ways to reduce CSA. However, no study has compared the effect of different acromioplasties on the reduction of the large CSA (≥33°) clinically. Additionally, either anterolateral or lateral acromioplasty could not precisely correct large CSAs to a favorable range (30–33°) in each patient. Thus, we will propose a novel precise acromioplasty technique for the purpose of reducing CSA accurately and effectively, and compare the effectiveness of different acromioplasties on the reduction of the CSA.

Methods

A total of 60 RCT patients who have indications for arthroscopic rotator cuff repair and with pre-operative CSA ≥33° will be recruited in outpatient center of Sun Yat-sen Memorial Hospital. Eligible participants will be randomly allocated to Group A (anterolateral acromioplasty), Group B (lateral acromioplasty) or Group C (precise acromioplasty) via a random, computer-generated number system. Three surgical plans will be made for each participant respectively by one professional surgeon according to the results of randomization allocation. The post-operative CSA will be measured 2 days post-operation. Follow-up will be maintained at 3, 6, and 12 months after surgery including the visual analog scale score, the University of California at Los Angeles score, the Constant Shoulder Score and the American Shoulder and Elbow Surgeon Shoulder Assessment Form. Finally, all outcomes will be assessed by two researchers who are blinded to the recruitment and allocation.

Discussion

This is the first clinical trial to evaluate the impact of different acromioplasties on the reduction of the CSA. Additionally, this study will provide a new precise acromioplasty technique, which is a novel precision and individualized treatment to prevent degenerative RCTs by reducing the CSA.

Trial registration

ChiCTR2000032343. Registered on April 26th, 2020.

Does anterior acromioplasty reduce critical shoulder angle?

INTRODUCTION

Critical shoulder angle (CSA) is the angle between glenoid inclination and the lateral edge of the acromion. CSA>35° has been shown to be a risk factor for primary and iterative rotator cuff tendon tear. The present study aimed to assess change in CSA after anterior acromioplasty. The study hypothesis was that CSA is significantly reduced.

METHOD

A single-center retrospective descriptive observational study included patients undergoing open or arthroscopic anterior acromioplasty, with strict AP pre- and post-operative radiographs. Patients with radiographs not meeting Moor's criteria were excluded.

RESULTS

One hundred and forty-eight patients were included: arthroscopy, 112; open surgery, 36. Mean age was 57.8 years (range, 29-80 years). Mean preoperative CSA was 36.1±4.25° (range, 25-48.4°) and postoperative CSA 33.5±3.9° (23.8-45.2°), for a significant reduction of -2.6±2.5° (p=0.001). Surgical technique did not affect change in CSA: open surgery, -2.3±1.9° (-6.3° to -1°); arthroscopy, -2.7±2.7° (-10.5° to -5°) (p=0.06). In pathologic CSA (>35°), the mean reduction was -3.2±2.6° (-10.5°to -5°). CSA normalized below the 35° threshold in 48% of patients.

DISCUSSION

Despite reduction in CSA, the 35° threshold for iterative tear is not always reached after anterior acromioplasty. Complementary strictly lateral resection is theoretically required. However, change in CSA is difficult to predict intraoperatively.

CONCLUSION

Anterior acromioplasty significantly reduced CSA, independently of technique and preoperative value.

LEVEL OF EVIDENCE

IV, retrospective descriptive study.

Type 1 Complex Regional Pain Syndrome After Subacromial Shoulder Surgery: Incidence and Risk Factor Analysis

INTRODUCTION

Complex Regional Pain Syndrome type 1 (CRPS1) is a potential complication, affecting the prognosis of functional joint recovery. Its incidence ranges from 2 to 40% depending on the series and the joints involved. Very few studies have evaluated the incidence of CRPS after shoulder surgery. The objective of our study was to determine the incidence of CRPS1 and to identify any pre-operative risk factors associated with its emergence after extra-articular subacromial space surgery.

MATERIAL AND METHODS

This is a retrospective single-centre study of patients who underwent surgery for a subacromial extra-articular shoulder pathology from January 2016 to December 2016 and included a follow-up period of at least 6 months. The primary inclusion criterion was developing a CRPS1 as defined by Veldman. A pre- and post-operative clinical assessment was performed based on the Constant (Cst) score.

RESULTS

Among the 287 patients, with an average follow-up period of 6.5 months, included in the study, 38 (13%) presented with post-operative CRPS1. Treated hypothyroidism (OR = 3.79; 95% CI 1.58;9.07; p = 0.003), open surgery (OR = 2.92; 95% CI 1.35-6.32; p = 0.007) and the level of daily physical activity from the Cst score (OR = 0.088; 95% CI 0.79;0.97; p = 0.015) were found to be significantly associated with the onset of CRPS1.

CONCLUSION

CRPS1 affected more than 10% of patients who underwent surgery for a subacromial shoulder pathology. The current study identified hypothyroidism, open surgery, and pre-operative clinical status as risk factors for the onset of this complication. These parameters should, therefore, be taken into consideration during the patient's pre-operative consultation.

A randomized prospective study

INTRODUCTION

There is no consensus on how to perform acromioplasty, particularly regarding the level and extent of bone resection, which depend on scapular and humeral morphologies.

HYPOTHESIS

We aimed to determine whether computer-assisted acromioplasty planning helps surgeons remove impinging bone, reduce unnecessary resections, and improve short-term outcomes of rotator cuff tears (RCR).

PATIENTS AND METHODS

We randomized 64 patients undergoing RCR of full-thickness supraspinatus tears into two groups: 'guided acromioplasty' (GA) and 'freehand acromioplasty' (FA). The pre- and post-operative scapula models were reconstructed using computed-tomography scans to quantify impinging bone removal, unnecessary bone resections, and identify zones of acromial bone removal. All patients were evaluated preoperatively and at 6 months to assess their range of motion (ROM), functional scores and tendon integrity using ultrasound.

RESULTS

The two groups did not differ in demographics, clinical or morphologic characteristics. Compared to FA, GA tended to lower impinging bone removal (55±26% vs. 43±27%, p=0.087) and to increase unnecessary resection of the total bone removed (49±22% vs. 57±27%, p=0.248). GA resulted in significant anterior under-resection, while FA resulted in significant medial over-resection. Clinical outcomes and ROM improved significantly for all patients, except for internal rotation in the GA group. There were no other significant differences between the two groups, neither in terms of post-operative scores nor in terms of clinical net improvements, nor tendon repair integrity.

CONCLUSIONS

This computer-assisted planning for acromioplasty during RCR proved no benefits in terms of bone removal, tendon healing, or clinical outcomes. Nonetheless such planning tools could help less experienced surgeons improve the efficacy of acromioplasty.

LEVEL OF PROOF

I, Randomized controlled trial (Therapeutic study).

Acromioplasty in the surgical operations of partial-thickness rotator cuff tears: A comprehensive review

The partial-thickness rotator cuff tears (PTRCTs) are known as a prevalent pathology, which cause inability mostly in athletes. So far, a number of treatments have been suggested depending on patient characteristics and size and location of the tears. Surgical repair in rotator cuff tears that include 50% or more of the tendon thickness is the accepted practice in the following failure of nonoperative treatment. In the surgical procedure, acromioplasty is known as a long-established component and used to modify the detrimental acromion morphology, which accounts for rotator cuff tearing. A range of trials has been reported that compare the results of surgical procedure with and without acromioplasty in patients undergoing rotator cuff repairs. According to the findings of 15 studies including ~1,500 patients, with mean age 60 years (range 5-80 years) and mean follow-up of 22 months (range 13-26 months) found by searching on Cochrane Register of Controlled Trials databases, Excerpta Medica/Embase, and Medline/PubMed, we revealed that acromioplasty cannot present an impressive effect on patient outcome scores at intermediate and short-term follow-ups. In fact, despite the theoretic advantages of acromioplasty in the setting of PTRCTs, it has reported little or no efficacy on outcomes of postoperative patients.

Radiofrequency microtenotomy: a promising method for treatment of rotator cuff tendinopathy

PURPOSE

Subacromial pain syndrome is a common disorder. Arthroscopic subacromial decompression is currently the preferred treatment method. Bipolar radiofrequency microtenotomy has shown promising results in treating tendinosis. In this study, the authors compare the results after arthroscopic acromioplasty with bipolar radiofrequency microtenotomy for patients with subacromial pain syndrome.

METHODS

A total of 27 patients, with subacromial pain syndrome, were followed for 2 years. There were 14 patients in the arthroscopic acromioplasty group and 13 patients in the radiofrequency microtenotomy group. Clinical outcome data included pain reported using a visual analog scale, Constant score, and strength. Magnetic resonance imaging of the affected shoulder was performed before and 2 years after intervention for an evaluation of the tendinosis grade.

RESULTS

All patients attended the final follow-up 2 years after intervention. No significant differences were found at baseline between the groups. Pain measured by the visual analog scale revealed a significant reduction in both groups at 12 weeks, 6 months and 2 years compared with baseline. There was no significant difference between the groups in terms of visual analog scale, Constant score, or strength. The magnetic resonance imaging revealed a significant improvement in the tendinosis score in both groups, without any significant difference between the groups.

CONCLUSION

In this prospective randomized study, the clinical assessments revealed a significant improvement in terms of the visual analog scale, strength, Constant score, and tendinosis score 2 years after intervention with either arthroscopic acromioplasty or radiofrequency microtenotomy in patients with subacromial pain syndrome. However, no significant differences were found between the groups. This study reveals that there are surgical options other than acromioplasty in patients with SAPS.

LEVEL OF EVIDENCE

II.

Does the critical shoulder angle decrease after anterior acromioplasty?

INTRODUCTION

No clinical studies to date have analyzed the critical shoulder angle (CSA) following anterior acromioplasty. Our study's main objective was to measure the change in the CSA after acromioplasty.

MATERIALS AND METHODS

Ninety patients were included in this retrospective series. The CSA and the type of acromion were evaluated before and after surgery.

RESULTS

The average CSA for patients before surgery was 35.9° (± 3.7, 26.2, 44.2) and 33° after the acromioplasty (± 3.5, 24.8, 41.4). The decrease was significant and 2.9° on average (± 2.2, - 2.2, 11.9, p = 0.000). Preoperatively, 58% of patients had a CSA ≥ 35° (n = 52) and 24% postoperatively (n = 22, p = 0.000).

CONCLUSIONS

Standardized anterior acromioplasty allows for a significant decrease in the CSA without lateral resection of the acromion. This study confirms the tight link between the CSA and the anterior acromion as well as the interest of this angle to quantify acromioplasty whether anterior or lateral.

LEVEL OF EVIDENCE

Level IV, Case Series, Retrospective design.

Influence of the site of acromioplasty on reduction of the critical shoulder angle (CSA) - an anatomical study

Background

A large critical shoulder angle (CSA) >35° is associated with the development of rotator cuff tearing. Lateral acromioplasty (AP) has the theoretical potential to prevent rotator cuff tearing and/ or to reduce the risk of re-tears after repair. It is, however unclear which part of the lateral acromion has to be reduced to obtain the desired CSA. It was the purpose of this study to determine which part of the lateral acromion has to be resected to achieve a desired reduction of the CSA in a given individual.

Methods

First, the influence of the exact radiographic projection on the CSA was examined. Second, the influence of anterolateral versus strict lateral AP on the CSA was studied in eight scapulae with different anatomic characteristics. Differences in CSA reduction were investigated using paired t-test or Wilcoxon test.

Results

Scapular rotation in the sagittal and axial plane had a marked influence on the radiologically measured CSA ranging from -6 to +16°. Overall, lateral AP of 5/10mm reduced the CSA significantly greater than anterolateral AP of 5mm/10mm [5mm: 2.3° (range: 0.7°-3.6°) SD±0.8° vs. 1.2° (range: 0°-3.3°) SD±1.1°, p=0.0002]/[10mm: 4.8° (range: 2.1°-7°) SD±1.3° vs. 2.7° (range: 0°-5.3°) SD±1.7°, p=0.0001]. Depending on scapular anatomy anterolateral AP did not alter CSA at all.

Conclusions

For comparison of pre- and postoperative CSA, the exact orientation of the X-ray and the spatial orientation of the scapula must be as identical as possible. Anterolateral AP may not sufficiently correct CSA in scapulae with great acromial slopes and smaller relative external rotation of the acromion as the critical acromial point (CAP) may be located too posteriorly and thus is not addressed by anterolateral acromioplasty. Consistent reduction of the CSA could be achieved by lateral AP in all eight scapulae.

ArthroPlanner: a surgical planning solution for acromioplasty

PURPOSE

We present a computer-assisted planning solution "ArthroPlanner" for acromioplasty based on 3D anatomical models, computed tomography and joint kinematic simulations.

METHODS

In addition to a standard static clinical evaluation (anamnesis, radiological examination), the software provides a dynamic assessment of the shoulder joint by computing in real time the joint kinematics from a database of activities of daily living. During motion, the precise bone resection (location and amount) is computed based on detected subacromial impingements, providing surgeons with precise information about the surgical procedure. Moreover, to improve the subjective reading of medical images, the software provides 3D measurement tools based on anatomical models assisting in the analysis of shoulder morphological features.

RESULTS

We performed an in vivo assessment of the software in a prospective randomized clinical study conducted with 27 patients beneficiating from the planning solution and a control group of 31 patients without planning. Postoperatively, patient's pain decreased, and the shoulder range of motion and the functional outcomes improved significantly and the rotator cuff healing rate was good for both groups without intergroup differences. The amount of bone resected at surgery was comparable between the groups. The percentage of remaining impingement after surgery was in average reduced to 51% without groups difference.

CONCLUSIONS

ArthroPlanner software includes all required materials (images data, 3D models, motion, morphological measurements, etc.) to improve orthopedists' performance in the surgical planning of acromioplasty. The solution offers a perfect analysis of the patient's anatomy and the ability to precisely analyze a dynamic mechanism to fully apprehend the patient's condition and to fulfill his/her expectations. The study however failed to detect any statistically significant difference in clinical outcomes and bone resection between the groups. Short-term clinical and radiological results were excellent in both groups.

Acromioplasty in patients selected for operation by national guidelines

BACKGROUND

Shoulder impingement syndrome is the most common shoulder disorder. Even though conservative treatment is the primary treatment of choice, surgery has increased substantially in several countries during the last 20 years. This has resulted in recommended clinical guidelines for treatment of shoulder impingement syndrome in countries such as The Netherlands and Denmark during recent years. The aim of this study was to investigate the effectiveness of an arthroscopic subacromial decompression in 244 patients selected for surgery according to national clinical guidelines.

MATERIALS AND METHODS

Patients were included from an Internet-based shoulder and elbow database. They were asked to complete 2 questionnaires consisting of the Oxford Shoulder Score (OSS) and the EuroQol 5-Dimension 3-Level and visual analog scale preoperatively and at 6-month follow-up. All patients were carefully selected for surgery according to the national guidelines, with symptoms persisting for at least 6 months. Furthermore, subgroups related to the OSS were formed to assess the clinical outcome according to preoperative status and age.

RESULTS

For the complete study group, an OSS change of 10 (8.8-11.2; P = .0001) was found at 6-month follow-up. No significant difference was found between the genders (P = .17). The largest clinical effect from the intervention was found in the low preoperative OSS (pre-OSS) group, in which a mean change of 17 was found. The moderate and high pre-OSS groups had mean changes of 13 and 5, respectively. Similarly, according to the EuroQol 5-Dimension 3-Level and visual analog scale, the largest improvements were seen in the low and moderate pre-OSS groups.

CONCLUSION

Arthroscopic subacromial decompression is a valid treatment, reducing pain and improving quality of life for patients selected for surgery according to the Danish national guidelines.

The correlation of supraspinatus outlet view with computed tomography for visualization of the anterior acromial undersurface

INTRODUCTION

Understanding the real shape of the undersurface of the acromion prior to acromioplasty is indispensable. Today, Supraspinatus outlet view (SSOV) is a standard view used to determine the shape of the anterior acromion. Three types of acromial undersurface were described by Bigliani and Morrison. The purpose of this study was to find out whether the real acromial type can be visualized on X-ray SSOV and compare the shape of the anterior undersurface of the acromion visualized on SSOV, with the shape revealed on 2D CT reconstructions.

METHODS

The SSOV X-rays and CT scans of 30 consecutive patients suffering from rotator cuff dysfunction were retrospectively analyzed. The shape of the acromion visualized on plain X-rays was classified according to Bigliani and Morrison classification system. Two-dimensional CT reconstructions were performed, reproducing the lateral, middle, and medial sections of the acromion. The acromial type that was visualized on each of those reconstructions was separately classified according to the Bigliani and Morrison system. A complete profile of the acromial undersurface was constructed from the integration of acromial types seen on each CT section. The acromial morphology seen on X-rays and CTs was compared.

RESULTS

A total of 30 patients comprised the study cohort; mean age was 57 (STD = 8.5) years. Three Type I, 22 Type II, and 5 Type III acromions were visualized on the SSOV X-rays. CT reconstructions revealed seven different morphological acromial profiles (I,I,I; I,II,II; I,II,III, etc.), which we divided into 3 groups: (1) Uniform (30%), (2) Internally curved (20%), and (3) Internally hooked (50%). The acromial type visualized on X-ray correlated with the acromial type on at least one CT section in all of the cases. In the case of uniform acromial profile, there is a full correlation between the acromial type visualized on X-rays and the type visualized on CT. In non-uniform profiles, there was an incomplete correlation between the types of the acromion visualized on SSOV and CT. SSOV X-rays correlated with or underestimated, but never overestimated, the acromial morphological type.

DISCUSSION

The curved or hooked portion of the acromial undersurface is not always visualized on the SSOV. On X-rays, the middle and lateral sections are seen more accurate than the medial section.

CONCLUSION

Surgeons should be aware that SSOV X-rays may underestimate the true type of the acromial undersurface.

Implementation of conservative treatment prior to arthroscopic subacromial decompression of the shoulder

PURPOSE

The aim of the study was to investigate to what extent patients undergo evidence-based conservative treatment prior to arthroscopic subacromial decompression of the shoulder.

METHODS

One hundred and twenty patients (65 women, 55 men, median age 53.5 years (range 28-70), referred to arthroscopic subacromial decompression at two hospitals in Norway, were consecutively included in the study. The patients completed a self-administered questionnaire including questions concerning the quantity and nature of preoperative treatment as well as the QuickDASH score. They were specifically asked for the extent of evidence-based conservative treatment, i.e. the combination of strengthening and stretching exercises at a minimum weekly amount and total duration.

RESULTS

One hundred and nine patients (91 %) reported having received conservative treatment guided by a physiotherapist preoperatively. The patients' main reasons for not seeing a physiotherapist were lack of trust in the treatment (N = 7) and the assumption that surgery would provide faster relief of symptoms (N = 6). Of those visiting a physiotherapist, 80 % received specific shoulder exercises. Forty-five per cent did both strengthening and stretching exercises, only 32 % did the exercises three times per week more than 2 months, and 24 % did more than 3 months as recommended. Seventy-six per cent of the patients who discontinued the prescribed exercise programme did this due to increasing pain.

CONCLUSIONS

Most of the patients in the current study reported having visited a physiotherapist before surgery. However, less than half of them underwent evidence-based exercise treatment, and increased pain was the main reason for not completing the prescribed exercise treatment. The results might be of clinical relevance for physiotherapists treating patients with SAPS, but also for orthopaedic surgeons doing preoperative evaluations.

LEVEL OF EVIDENCE

Case series, IV.

Finnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT): a protocol for a randomised trial comparing arthroscopic subacromial decompression and diagnostic arthroscopy (placebo control), with an exercise therapy control, in the treatment of shoulder impingement syndrome

INTRODUCTION

Arthroscopic subacromial decompression (ASD) is the most commonly performed surgical intervention for shoulder pain, yet evidence on its efficacy is limited. The rationale for the surgery rests on the tenet that symptom relief is achieved through decompression of the rotator cuff tendon passage. The primary objective of this superiority trial is to compare the efficacy of ASD versus diagnostic arthroscopy (DA) in patients with shoulder impingement syndrome (SIS), where DA differs only by the lack of subacromial decompression. A third group of supervised progressive exercise therapy (ET) will allow for pragmatic assessment of the relative benefits of surgical versus non-operative treatment strategies.

METHODS AND ANALYSIS

Finnish Subacromial Impingement Arthroscopy Controlled Trial is an ongoing multicentre, three-group randomised controlled study. We performed two-fold concealed allocation, first by randomising patients to surgical (ASD or DA) or conservative (ET) treatment in 2:1 ratio and then those allocated to surgery further to ASD or DA in 1:1 ratio. Our two primary outcomes are pain at rest and at arm activity, assessed using visual analogue scale (VAS). We will quantify the treatment effect as the difference between the groups in the change in the VAS scales with the associated 95% CI at 24 months. Our secondary outcomes are functional assessment (Constant score and Simple shoulder test), quality of life (15D and SF-36), patient satisfaction, proportions of responders and non-responders, reoperations/treatment conversions, all at 2 years post-randomisation, as well as adverse effects and complications. We recruited a total of 210 patients from three tertiary referral centres. We will conduct the primary analysis on the intention-to-treat basis.

ETHICS AND DISSEMINATION

The study was approved by the Institutional Review Board of the Pirkanmaa Hospital District and duly registered at ClinicalTrials.gov. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT00428870; Pre-results.

Surgery for calcifying tendinitis of the shoulder: A systematic review

AIM

To systematically search literature and determine a preferable surgical procedure in patients with failed conservative treatment of calcifying tendinitis of the shoulder.

METHODS

The electronic online databases MEDLINE (through PubMed), EMBASE (through OVID), CINAHL (through EB- SCO), Web of Science and Cochrane Central Register of Controlled Trials were systematically searched in May 2016. Eligible for inclusion were all available studies with level II and level III evidence (LoE). Data was assessed and extracted by two independent review authors using a specifically for this study designed data extraction form.

RESULTS

Six studies (294 surgically treated shoulders) were included in this review. No significant differences between the three available treatment options (acromioplasty with the removal of the calcific deposits, acromioplasty or solely the removal of the calcific deposits) were detected regarding the functional and clinical outcome. The follow-up ranged from 12 mo to 5 years. Complication rates were low. No reoperations were necessary and the only reported complication was adhesive capsulitis, which in all cases could be treated conservatively with full recovery.

CONCLUSION

We found that all three available treatment options show good functional and clinical outcomes in the short and midterm. However, a favorable procedure is difficult to determine due to the lack of high-quality comparing studies.

Morphometric Evaluation of Adult Acromion Process in North Indian Population

INTRODUCTION

Dimensions of acromion process are important to show linkage to the shoulder girdle pathologies. Also morphometric analysis of acromion process would be helpful for surgeons while performing surgical procedures on the shoulder joint.

AIM

The purpose of this present study was to observe the detailed morphometric evaluation of adult acromion processes in North Indian population because different morphometric dimensions play an important role in various disorders of the shoulder, particularly sub acromial impingement syndrome.

MATERIALS AND METHODS

Two hundred adult dry scapulae from the osteology museum of MAMC, New Delhi, were obtained for evaluation of various measurement of acromion process. The length, width, thickness of acromion, coraco-acromial (C-A) distance and acromio-glenoid (Ac-g) distance were measured. The measurements were compared with other osteological studies performed on different population group. Data was analysed using SPSS version 12.0 and mean values with standard deviation for each dimension were presented.

RESULTS

The mean values of each measurement were: length: 41.007 mm; width: 21.82 mm; thickness: 6.58 mm; C-A distance: 28.34 mm and Ac-g distance: 26.21 mm.

CONCLUSION

It is expected that various dimensions of adult acromion process will serve as a reference base and will assist the surgeon in the approach to be used and precision of the operative technique. So, the study will provide a vital support for planning and executing acromioplasty in the treatment of impingement syndrome.

Does concomitant acromioplasty facilitate arthroscopic repair of full-thickness rotator cuff tears? A meta-analysis with trial sequential analysis of randomized controlled trials

PURPOSE

To conduct a meta-analysis with randomized controlled trials (RCTs) published in full text to determine the benefits of concomitant acromioplasty in repairing full-thickness rotator cuff tears.

METHODS

Literature search was performed in PubMed, Embase and the Cochrane Library from databases inception through February 2016 to identify RCTs evaluating the efficacy of performing a concomitant acromioplasty. Statistical heterogeneity among studies was quantitatively evaluated by I-squared index (I(2)) and trial sequential analysis (TSA) was applied to control random errors.

RESULTS

Five RCTs totaling 523 patients were included. There was no statistically significant difference in Constant score (WMD = 1.00; 95 % CI -4.40 to 6.41; P = 0.72), University of California-Los Angeles (UCLA) score (WMD = 0.48; 95 % CI -0.79 to 1.76; P = 0.46), visual analog scale (VAS) for pain (WMD = -0.23; 95 % CI -0.58 to 0.11; P = 0.19) and re-tear rate (RR = 0.46; 95 % CI 0.14 to 1.53; P = 0.21) between acromioplasty group and the nonacromioplasty group. However, it was found to be related to a greater increase in American Shoulder and Elbow Surgeons (ASES) score (WMD = 3.02; 95 % CI 0.24 to 5.80; P = 0.03). Unfortunately, this difference was not reinforced by subsequent TSA. In addition, subgroup analysis showed no substantial difference of ASES score in patients with type-1 (WMD = -8.21; 95 % CI -23.55 to 7.14; P = 0.29), type-2 (WMD = 0.97; 95 % CI -5.10 to 7.05; P = 0.75), or type-3 (WMD = 2.32; 95 % CI -9.96 to 14.61; P = 0.71) acromion.

CONCLUSIONS

A significant higher ASES score was observed during the comparison despite lacking reinforcement by TSA. No difference was found in Constant score, UCLA score, VAS, re-tear rate and subgroup analysis did not confirm the impact of acromion type on eventual therapeutic outcome. Future studies with large number of participants, long-term follow-ups, data of patient-reported outcomes and stratification for acromion type are of the essence for demonstrating whether functional or structural differences exist in patients undergoing arthroscopic repair of full-thickness rotator cuff tears with or without acromioplasty.

Arthroscopic treatment of non-homogeneous calcifying tendinitis of the rotator cuff

The purpose of this study is to investigate the clinical outcome of arthroscopic treatment for patients with non-homogeneous infiltrated calcifying tendinitis of the rotator cuff (type III), and to assess the optimal method for this arthroscopic treatment. We retrospectively reviewed the charts of 81 patients who underwent arthroscopic treatment for non-homogeneous infiltrated calcifying tendinitis of the rotator cuff (type III). Patients were divided into two groups: Group A (n = 31) consisted of patients who underwent excision of calcification, and Group B comprised patients who underwent acromioplasty alone (n = 50). The clinical outcome of treatment was assessed using Constant-Murley score. Twenty-three of the 81 patients were males and 58 were females. The mean duration of symptoms from onset to the first clinic visit was 3.88 years (SD ± 3.06 years). The right side was involved in 47 patients, the left side in 34 patients, and none had bilateral involvement. Patients from Group B had higher 16 improvement of their Constant-Murley score (from 48.96 to 88.06) when 17 compared to group A (from 45.39 to 67.23). Treatment of type III calcifying tendinitis is different than type I and II. Subacromial decompression may be considered in all patients suffering from type III non-homogeneous infiltrated calcifying tendinitis of the shoulder.

Current UK practices in the management of subacromial impingement

BACKGROUND

Controversy presently exists surrounding the management of patients with subacromial impingement. This study aims to highlight current UK practices in the management of these patients.

METHODS

BESS members were invited to complete a questionnaire and responses were received from 157 consultant shoulder surgeons.

RESULTS

Physiotherapy is an integral part of management for 93% of surgeons with a minimum period of 12 weeks being most popular prior to consideration of arthroscopic subacromial decompression. Subacromial steroid injection is used by 95% and 86% repeat this if the patient has failed to respond to a previous injection by the general practioner. From initial presentation, 77% felt there should be at least 3 months of conservative management before proceeding to surgery. Good but transient response to subacromial injection was considered the best predictor of good surgical outcome by 77%. The coracoacromial ligament is fully released by 78%, although there was greater variation in how aggressive surgeons were with acromioplasty. Most (59%) do not include the nontender acromioclavicular joint to any extent in routine acromioplasty. Hospital physiotherapy protocols are used by 63% for postoperative rehabilitation.

CONCLUSIONS

Variation exists in the management regimes offered to patients with subacromial impingement, but most employ a minimum period of 12 weeks of conservative management incorporating physiotherapy and at least 2 subacromial steriod injections.

Outcomes are favorable in Asian patients undergoing deltoid-on open rotator cuff repair without acromioplasty

BACKGROUND

To evaluate if rotator cuff repair without acromioplasty would result in improvement in outcomes without the risks associated with acromioplasty in Asian patients.

METHODS

38 primary repairs of tears of the rotator cuff were performed through a deltoid-on approach. The Simple Shoulder Test (SST) and UCLA shoulder rating scale were measured preoperatively and at 2 years post-operatively.

RESULTS

There was a significant improvement in the SST 2 years post-operatively (p < 0.001). UCLA scores for pain control and function (p < 0.001) also significantly improved 2 years post-operatively.

CONCLUSION

Outcomes are favorable in Asians following deltoid-on open rotator cuff repair without acromioplasty.

LEVEL OF EVIDENCE

III.

Is rotator cuff repair appropriate in patients older than 60 years of age? prospective, randomised trial in 103 patients with a mean four-year follow-up

BACKGROUND

The objective of this randomised trial was to compare surgical rotator cuff repair to simple decompression by acromioplasty and biceps tenotomy in patients older than 60 years of age with a mean follow-up of 4 years.

HYPOTHESIS

Tendon repair produces better functional outcomes than simple decompression and prevents progression towards cuff tear arthropathy in the longer term.

PATIENTS AND METHOD

Of 130 initially included patients older than 60 years of age and having rotator cuff tears deemed amenable to surgical repair, 103 (79%) were evaluated after a mean of 4 years. These patients had been randomly allocated to acromioplasty and tenotomy (AT group, n=49) or to acromioplasty, tenotomy, and tendon suture (CR group, n=54). The tear was distal in 41 patients, intermediate in 40, and retracted in 22. At last follow-up, the evaluation included the clinical Constant's Score, radiographs and, in the CR group, ultrasonography.

RESULTS

The complication rate was 4%. The mean Constant Score was 44 preoperatively; values after 4 years were 76 overall (P=0.01), 78 in the CR group, and 73 in the AT group (P=0.01). The tendon-healing rate as assessed using ultrasonography was 63%. The Constant Score was significantly better when tendon healing was achieved (82/73, P<0.001). In the AT group, the acromio-humeral distance was significantly shorter (6.9 mm/7.8mm, P=0.03) and eccentric humeral head position was more common (44%/26%, P=0.01).

DISCUSSION

Arthroscopic rotator cuff repair provides better functional outcomes than does simple decompression in patients older than 60 years and prevents cuff tear arthropathy with eccentric humeral head position in the medium term. Tendon healing is the main determinant of outcomes after rotator cuff repair.

LEVEL OF EVIDENCE

II, randomised trial.

Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis

OBJECTIVE

To investigate the evidence on effectiveness of surgery for shoulder impingement compared with conservative treatment.

DATA SOURCES

Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL and Science Citation Index databases were searched in March 2013 unrestricted by date or language.

STUDY SELECTION

Controlled randomized (RCT) or quasi-randomized clinical trials comparing surgery and conservative treatment of shoulder impingement were included.

DATA EXTRACTION

The methodological quality of each included trial was assessed according to the Cochrane Collaboration's domain-based evaluation framework.

DATA SYNTHESIS

Of seven included RCTs, risk of systematic bias was considered to be low for two, high for four, and unclear for one RCT. The random-effect meta-analysis was conducted on four RCTs involving 347 subjects (173 surgically treated cases and 174 controls). There was no significant difference in changes in pain intensity between surgically and conservatively treated subjects (Hedges's g = 0.01 in favor of conservative treatment, 95% CI -0.27 to 0.30).

CONCLUSION

Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. There was, however, moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Implications for Rehabilitation Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. There was moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Because of surgery's higher costs and susceptibility for complications compared with costs and risks of conservative treatment, conservative treatment can be recommended as a first choice of treatment of shoulder impingement in first or second grade.

The role of acromioplasty for rotator cuff problems

Acromioplasty is a well-described technique used throughout the wide spectrum of treatment options for shoulder impingement and rotator cuff pathology. Several randomized prospective studies have described clinical outcomes that are statistically similar when comparing patients undergoing rotator cuff repair either with or without concomitant acromioplasty. This article reviews the current evidence for use of acromioplasty in patients with subacromial impingement syndrome and during arthroscopic rotator cuff repair. Despite recently published studies, more long-term data, especially with regard to failure rates and return-to-surgery rates over time, are needed to better determine the role of acromioplasty.

Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England

We explored the trends over time and the geographical variation in the use of subacromial decompression and rotator cuff repair in 152 local health areas (Primary Care Trusts) across England. The diagnostic and procedure codes of patients undergoing certain elective shoulder operations between 2000/2001 and 2009/2010 were extracted from the Hospital Episode Statistics database. They were grouped as 1) subacromial decompression only, 2) subacromial decompression with rotator cuff repair, and 3) rotator cuff repair only. The number of patients undergoing subacromial decompression alone rose by 746.4% from 2523 in 2000/2001 (5.2/100 000 (95% confidence interval (CI) 5.0 to 5.4) to 21 355 in 2009/2010 (40.2/100 000 (95% CI 39.7 to 40.8)). Operations for rotator cuff repair alone peaked in 2008/2009 (4.7/100 000 (95% CI 4.5 to 4.8)) and declined considerably in 2009/2010 (2.6/100 000 (95% CI 2.5 to 2.7)). Given the lack of evidence for the effectiveness of these operations and the significant increase in the number of procedures being performed in England and elsewhere, there is an urgent need for well-designed clinical trials to determine evidence of clinical effectiveness.

Treatment of non-traumatic rotator cuff tears: A randomised controlled trial with one-year clinical results

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.

No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial

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.

Surgery of subacromial syndrome with application of plasma rich in growth factors

Background

Our objective was to evaluate clinical recovery of patients with subacromial syndrome, after administering them plasma rich in growth factors (PRGF) by means of the Constant, University of California Los Angeles (UCLA) and Dissabilities of Arm, Shoulder and Hand (DASH) tests.

Materials and Methods

Prospective cohort study involving two groups — group A, treated with PRGF (52 patients); and group B, without PRGF treatment (79 patients). We analyzed the clinical situation preoperatively (time 1), at 1 month (time 2) and after rehabilitation (time 3).

Results

We considered 131 patients (71.2% were men, with median age of 53.7 years). Different approaches were used — traditional (62.5%), mini-open (22.5%) and arthroscopic (15%), without significant differences (P= .71). We observed improvement in the Constant test results at time 2 (59.8 ± 11.5 points in group A vs. 13.2 ± 7.1 points in group B; P < .05) and at time 3 (79.3 ± 11.6 points in group A vs. 59.7 ± 20.1 points in group B; P ¼ .05). We found improvement in the UCLA test results at time 2 (23.2 ± 5.8 points in group A vs. 4.72 ± 1.1 points in group B; P < .05) and at time 3 (32.1 ± 5.3 points in group A vs. 22.1 ± 7.35 points in group B; P < .05). We also observed improvement in the DASH test results at time 2 (45.2 ± 17.2 points in group A vs. 118.3 ± 7.6 points in group B, P < .05) and at time 3 (37.3 ± 12.6 points in group A vs. 69 ± 25.7 points in group B). Time of rehabilitation reduced significantly: 2.53 months in group A vs. 4.96 months in group B (P < .05). No significant differences were observed in surgical times: 88 minutes (group A) vs. 97 minutes (group B).

Conclusion

In our experience, PRGF should be indicated in subacromial syndrome and cuff involvement, as shown by the improvement in our results in terms of better results of tests, reduction in rehabilitation time and no increase in operation time.

Comparison of surgical outcome in impingement syndrome with and without stiff shoulder

BACKGROUND

In impingment syndrome with associated stiff shoulder the general protocol of management is to conservatively treat the stiff shoulder followed by operative treatment of the impingement syndrome. This consecutive prospective study was carried out to evaluate the functional outcome of surgical management for impingement syndrome associated with stiff shoulder and to compare the results with surgical management of impingement syndrome alone.

MATERIALS AND METHODS

We evaluated a total of 100 patients with impingement syndrome, consisting of 76 patients with impingement syndrome alone (Group A) and 24 patients of stiff shoulder associated with impingement syndrome (Group B). Group A patients were treated by subacromial decompression alone and Group B patients were treated by closed manipulation under anesthesia followed by subacromial decompression.

RESULTS

According to the American Shoulder and Elbow Surgeons (ASES) evaluation score satisfactory results were obtained in 80% patients of Group A and 67% patients of Group B, while for patients with diabetes [(n = 18), Group A (n = 11), Group B (n = 7)] satisfactory results were achieved in 82% of patients of Group A(9/11) and 43% of Group B(3/7). Overall, Group B patients had a lower range of motion for external rotation postoperatively, thus indicating that procedures to improve the external rotation, such as a release of the rotator interval or anterior capsule, might be considered in conjunction with other surgical procedures in patients with impingement syndrome with associated stiffness to further improve functional outcome.

CONCLUSION

Acromioplasty can be performed in stiff shoulder associated with impingement syndrome without fears of further worsening of stiffness from adhesions with the exposed raw undersurface of acromian. Patients with diabetes mellitus and shoulder stiffness tend to have poor clinical outcomes and must receive appropriate counseling preoperatively.