Shoulder Arthroscopy - Subacromial Bursectomy:

- Surgical Considerations: (arthroscopic rotator cuff repair / acromioplasty)
   - note that the subacromial bursa is an anterior structure;
   - it is located from anterior 1/2 to 1/3 of acromion to just medial to A-C joint to 1 to 2 cm anterior to acromion & 2.5 cm laterally;
   - posterior busrsal wall is thick posteriorly (called posterior bursal curtain)
            - this posterior bursal curtain frequently “closes” as the scope is backed posteriorly to get a larger field;
            - it may be necessary to resect a portion of this structure to visualize the entire arch;
   - when introducing instruments into the subacromial bursa, use the blunt trochar sheath is lyse adhesions from the undersurface of
           the acromion and the lateral part of the deltoid;
   - elements of bursectomy:
           - needs to be compulsive and complete for appropriate visualization;
           - there needs to be complete removal down to the subdeltoid space;
           - there should be complete visualization 1 cm medial to both the anterior and posterior arthroscopic portals;
           - OR descriptions bursal proliferation and inflammation, hemorrhaging in CA ligament, hypertrophy and fraying of CA
                     ligament, acromial spur formation;
   - bursa is sometimes debrided after the acromioplasty, since it tends to bleed more (disrupting the case);
                - take special when debriding around the AC joint since bleeding is especially troublesome;
   - rotate the arm internally and externally to expose different parts of the bursa;
   - downward traction generally increases the working space available for the subacromial space. 
   - use of a radiofrequency device before a motorized shaver is used for bursectomy can help to minimize bleeding;
   - methodically sweep the shaver along the bursa;
   - references:
         - Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study.
         - Surgical repair of rotator cuff ruptures. The importance of the subacromial bursa.
         - Subacromial Decompression Versus Subacromial Bursectomy for Patients With Rotator Cuff Tendinosis
         - Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: a 2-year randomised controlled trial.
         - Bursectomy and acromial resection in arthroscopic treatment of sub-acromial impingement
         - Involvement of the anterior portion of the subacromial-subdeltoid bursa in the painful shoulder.
         - Adhesion of the subacromial bursa may cause subacromial impingement in patients with rotator cuff tears: pressure measurements in 18 patients.

- Basic Science:
         - Vascular endothelial growth factor 121 and 165 in the subacromial bursa are involved in shoulder joint contracture in type II diabetics with rotator cuff disease..
         - The molecular pathophysiology of subacromial bursitis in rotator cuff disease.
         - Proinflammatory cytokines and metalloproteases are expressed in the subacromial bursa in patients with rotator cuff disease.
         - Stromal cell-derived factor 1 (SDF-1, CXCL12) is increased in subacromial bursitis and downregulated by steroid and nonsteroidal anti-inflammatory agents.
         - Increased IL-1beta expression and myofibroblast recruitment in subacromial bursa is associated with rotator cuff lesions with shoulder stiffness.
         - Interleukin-1-induced glenohumeral synovitis and shoulder pain in rotator cuff diseases.

        - Improvement in Comfort and Function After Cuff Repair Without Acromioplasty 
        - Open rotator cuff repair without acromioplasty. 
        - Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes.
        - Débridement of Partial-Thickness Tears of the Rotator Cuff without Acromioplasty. Long-Term Follow-up and Review of the Literature
        - Arthroscopic Decompression with Acromioplasty and Structured Exercise Was No More Effective and Was More Expensive Than Exercise Alone 

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Saturday, October 4, 2014 9:18 am