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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