- Discussion, Indications and Outcomes:
- see:
open acromioplasty
- Radiographs:
- Positioning:
- beach chair position is comfortable for both the patient and the surgeon and allows the option of converting to an open procedure (if necessary);
- patients need to be seated with the torso raised to 70 deg with a foled sheet placed on the medial border of the affected scapula (to maximize posterior exposure)
- simultaneously palpate posterolateral corner and anterior of the acromion and note the "arthoscopic plane";
- if this plane is sloped too steeply, then the surgeon will have to hold the arthroscope in an awkward position (w/ the scope pointing upwards);
- to remedy this problem, increase the patient's sitting angle which will bring the arthroscopic plane down to a more horizontal level;
- complications: hypoglossal nerve injury;
- reference:
Hypoglossal nerve palsy after arthroscopy of the shoulder and open operation w/ the patient in the beach chair position.
RC Mullins et al. JBJS. Vol 74-A. 1992. p 137-139.
- Portal Placement:
- generally arthroscopy of the shoulder joint is carried out prior to arthroscopic acromioplasty, and therefore,
standard anterior and posterior arthroscopic portals are established;
- a self sealing cannula is usually placed thru the anterior portal;
-
anterior portal:
- the arthroscope is driven anteriorly until the tip can be palpated near the anterior portal;
- drive the arthroscope thru the anterior portal and then pull the scope back out of its cannula;
- the arthroscopic cannula serves as a positioning guide for the anterior cannula which is then driven into the subacromial space;
- a 5.5 mm shaver is placed into the anterior portal cannula and an inital arthroscopic bursectomy is carried out;
- one adequate visualization of the subacromial space has been established, the lateral portal is established;
-
lateral portal: (see
portal placement);
- used as the main instrument portal (acromioplasty and bursal debridement);
- lateral portal is inserted in the usual manner with care that its placement will allow full triangulation of the undersurface of the anterior acromion;
- Plan to Control Bleeding:
- pre-inject the subacromial space with 30 cc of 1:300,000 epinephrine solution;
- if possible, have anesthesia lower the patient's blood pressure;
- ensure that reserve fluid bags are present;
-
arthroscopic techniques:
- when the posterior subacromial portal is established, bluntly sweep the trocar across the undersurface of the acromion which helps
to remove the bursal attachments;
- minimize the use of the shaver to clear off the bursa, since this may stir up early bleeding;
- use cautery or the arthrocare wand to carefully define the undersurface landmarks of the acromion;
- be careful not to disturb the deltoid fascia which lies below the acromion since this is guaranteed to stir up bleeding;
-
air injection:
- if bleeding obstructs the visualization, then shut off inflow and suction out the fluid;
- inject 100 cc of air thru a syringe;
- bleeding will then usually stop spontaneously;
- Arthroscopic Decompressions:
- the
posterior portal is used to view the subacromial space, the lateral portal is used for instrumentation, and
the anterior portal is used for either outflow or inflow;
- a 6.5 mm cannula is inserted thru the anterior and lateral portals to accomadate the inflow and instrumentation;
- the first step usually involves a limited bursectomy using the 5.5 mm full radius shaver;
- it is essential to limit the bursectomy to the region around the anterior acromion, inorder to limit bleeding;
-
establish landmarks:
- the anterior portal serves as a landmark for the AC joint;
- undersurface of acromion is covered by periosteal layer & layer of coracoacromial ligament, which extends under acromion (this covering
is quite thick and extensive);
- the entire undersurface of the antero-lateral acromion is cleared of soft tissue using intra-articular cautery inorder to limit bleeding;
- take care not to stray into the deltoid fibers, since this will stir up bleeding and will ruin the case;
- once the bursal tissue is removed from the undersurface of the acromion, cautery is then used to remove bursal tissue and the deltoid
attachements on the anterior acromial surface;
- note that bleeding from branch of
thoracoacromial artery can easily occur when sectioning the coracoacromial ligament;
- Acromioplasty:
- arthroscopic impingement test:
- following removal of the inflamed bursal tissue an arthroscopic impingement test should bes performed;
- place the arthroscope through the lateral arthroscopic portal and then flex the shoulder (move back and forth from the scapular plane to straight forward);
- note any impingement between the humeral head and the acromion (following the acromioplasty no impingement should be observed and the subacromial
space should be maintained);
- as has been described by
Rockwood et al a two step acromioplasty is necessary;
-
anterior acromioplasty:
- ideally, the portion of the acromion which extends anterior to the anterior edge of the clavicle should be removed (this is often about
5 mm and can be estimated from the
30 deg caudal tilt view);
- place a 5 mm burr on the cuff, just below the acromial tip;
- this gives an indication of how much space is present, and when the acromioplasty is finished, the burr is again
used to judge the amount of space that is present;
- use the burr to remove the anterior 5 mm of the acromion, completing the most lateral side prior to removing the medial side of the acromioplasty;
- once the lateral half of the anterior acromion has been removed, it is easy to judge how much of the remaining acromion needs to be removed;
-
inferior acromioplasty: (second stage acromioplasty)
- use a burr to create a centering hole 2 mm deep in the undersurface of the acromion, which is located 5 mm posterior the anterior acromial
edge and which is located midway between the AC joint and the lateral aspect of the acromion;
- this centering hole is used to help plane the inferior acromioplasty;
- in some cases, it is helpful to switch the arthroscope to the lateral portal and place the burr in the posterior portal;
- Bursal Debridemnt:
- the bursa is 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;
- methodically sweep the shaver along the bursa;
- Controversies:
-
distal clavicle excision: (see
distal clavicle excision)
- in the study by BW Fischer MD et al (Arthroscopy, Vol 15, No 3 (April), 1999: pp 241-248), the authors studied the effect of
violation of the AC joint during arthroscopic acromioplasty;
- the authors found that patients that either had no violation of the AC joint or patients that had complete DCR had no postoperative
sequelae in reference to the AC joint;
- in contrast, 14 / 36 shoulders (39%) w/ documented AC joint violation and a partial DCR developed AC joint symptoms at an average of 8.4 months;
- authors recommend an all or nothing approach to the AC joint (ie avoid partial distal clavicle resection);
- recommended that if AC joint must be violated to perform an adequate decompression of the subacromial space, complete resection
of the distal clavicle should be performed, even if the radiographs show no preoperative degenerative changes;
- authors theorize that partial distal clavicle excision increases AC joint motion in all planes, especially rotation and superior translation,
after co-planing of the inferior surface;
- these authors proposed that the increased mobility could lead to acromioclavicular joint symptoms in a previously asymptomatic joint or
accelerate symptoms in a joint with mild symptoms before surgery;
- references:
- Incidence of Acromioclavicular Joint Complications After Arthroscopic Subacromial Decompression.
Arthroscopy: Vol 15, No 3 (April), 1999: pp 241-248 BW Fischer MD
-
AC Joint Reoperation After Arthroscopic Subacromial Decompression With and Without Concomitant AC Surgery
-
rotator cuff tear tear:
- as pointed out by
Gartsman et al, in a group of patients with partial thickness rotator tears, there was 33 satisfactory and 7 unsatisfactory results;
- as pointed out by
Gartsman et al, in a group of patients with full thickness rotator tears, there was 14 satisfactory and eleven satisfactory results;
- in this same group, 6 out of 7 patients that underwent subsequent rotator cuff repair had a satisfactory result;
- from
Altchek et al, 6 of 10 patients w/ a full thickness RTC, had a good or excellent result;
- these patients should generally expect some pain relief but no improvement in function from the arthroscopic acromioplasty;
-
posterior capsular release:
- may be indicated in selected patients, w/ limited internal rotation and w/ thickened posterior capsule who demonstrate persistent
impingement (as seen arthroscopically);
- technique involves arthroscopic visualization from the anterior portal and release of the posterior capsule off of the glenoid using cautery;
- references: Recognition and Treatment of Refractory Posterior Capsular Contracture of the Shoulder
The Journal of Arthroscopic and Related Surgery, Vol 16, No 1 (January-February/), 2000: pp 27-34
- Post Op:
- average time for full recovery is about 4 months;
Arthroscopic subacromial decompression versus open acromioplasty. A two-year follow-up study.
Arthroscopic acromioplasty for lesions of the rotator cuff.
Arthroscopic acromioplasty. Technique and results.
Arthroscopic debridement versus open repair for rotator cuff tears. A prospective cohort study.
Partial thickness rotator cuff tears: results of arthroscopic treatment.
Arthroscopic subacromial decompression versus open acromioplasty. A two-year follow-up study.
Arthroscopic treatment of massive rotator cuff tears. Clinical results and biomechanical rationale.
Rotator cuff pathology. Arthroscopic assessment and treatment.
Arthroscopic acromioplasty. Technique and results.
Arthroscopic acromioplasty for lesions of the rotator cuff.
Arthroscopic subacromial decompression: results in advanced impingement syndrome.
Progress in 1991--General Orthopaedics: Shoulder: Arthroscopic
Treatment of Massive Rotator Cuff Tears: Clinical Results and Biomechanical Rationale.
Shoulder impingement syndrome in athletes treated by an anterior acromioplasty.
Tibone, JE, Jobe FW, Kerlan RK, Carter VS, Shields CL, Lombardo SL, and Yocum LA. CORR 198: 134-140, 1985.
-
precautions:
- prior to inserting instruments into subacromial space it is helpful to prevent subacromial bleeding (or limit it before it occurs);
- pre-inject the subacromial space with an epinephrine containing solution;
- consider adding 1/2 ampule of epipnephrine to each 3 liter bag of NS;
- ensure that multiple fluid bags are ready;
- ensure that intra-articular cautery is ready;
- once the arthroscopic examination of the shoulder is completed, the arthroscope (
posterior portal) is pull out of the shoulder
joint and is driven into the subacromial space;
- if this portal has been placed too inferior, visualization of the subacromial joint may be difficult;
