Wednesday, November 22, 2017

Acromioplasty S.A.D: R.I.P.

The acromion is innocent.

Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised  surgical trial (see this link). Conclusions: "Surgical groups had better outcomes for shoulder pain and function compared with no treatment but this difference was not clinically important. Additionally, surgical decompression appeared to offer no extra benefit over arthroscopy only. The difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. The findings question the value of this operation for these indications, and this should be communicated to patients during the shared treatment decision-making process."

From NPR: "Popular Surgery To Ease Chronic Shoulder Pain Called Into Question" (see this link).

In 1934, Codman pointed out that the proximal humerus normally articulates with the coracoacromial arch, providing stability of the shoulder against superiorly directed loads. He stated that the coracoacromial arch “has an important duty and should not be thoughtlessly divided at any operation”. 

There is a tendency to confuse the association of cuff pathology and acromial changes with causation of the cuff changes by the acromion. Today, many hold the belief that ‘impingement” causes cuff lesions. By contrast, in 1972, Neer reported shoulders with a “characteristic ridge of proliferative spurs and excrescences on the undersurface of the anterior process (of the acromion) apparently caused by repeated impingement of the rotator cuff and the humeral head, with traction of the coracoacromial ligament”, in other words the changes in the acromion were a result of the cuff disease.

Over a decade ago, it was recognized that acromioplasty was not necessary for achieving a good result from rotator cuff repair (see this link).

Authors of a recent article (see Published Evidence Relevant to the Diagnosis of Impingement Syndrome) were unable to find good evidence to support any of these statements:  (1) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch, (2) spurs on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and (3) successful treatment of the “impingement syndrome” requires surgical alteration of the acromion and/or coracoacromial arch. 

In spite of the lack of evidence in support of its use, the rate of acromioplasty has been on the increase

Acromioplasty is not benign. Many of the cases coming for reverse total shoulder arthroplasty have anterosuperior escape resulting from the violation of Codman's admonition to preserve the coracoacromial arch.

Recently, it has been pointed out that the benefits previously ascribed to acromioplasty can be achieved without acromioplasty (see Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty at this link).

This week, the Journal Lancet published "Arthroscopic subacromial decompression for subacromial shoulder pain: a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial" (see this link). 

These authors did a multicenter, randomised, pragmatic, parallel group, placebo-controlled, three-group trial at 32 hospitals in the UK with 51 surgeons. Participants were patients who had subacromial pain for at least 3 months with intact rotator cuff tendons, were eligible for arthroscopic surgery, and had previously completed a non-operative management program that included exercise therapy and at least one steroid injection.
They randomly assigned 303 participants to receive (a) arthroscopic subacromial decompression, (b) investigational arthroscopy without acromioplasty, or (c) no treatment.

In the surgical intervention groups, patients were not told which type of surgery they were receiving (to ensure masking). 

At 6 months, data for the Oxford Shoulder Score were available for 90 patients assigned to decompression, 94 to arthroscopy, and 90 to no treatment. There was no difference between the average  Oxford Shoulder Scores of those patients receiving acromioplasty and those receiving arthroscopy without acromioplasty. Both surgical groups showed a small benefit over no treatment, but these differences were not clinically important. This difference between the surgical groups and no treatment might be the result of, for instance, a placebo effect or postoperative physiotherapy. 

Based on these findings, the authors question the value of acromioplasty.

Another recent article, (Declining incidence of acromioplasty in Finland, see this link) gives insight into factors affecting the incidence of acromioplasty: "The incidence of acromioplasty increased by 117% from 75 to 163 per 105 person years between 1998 and 2007. The highest incidence was observed in 2007, after which the incidence rate decreased by 20% to 131 per 105 person years in 2011. The incidence declined even more at non-profit public hospitals from 2007 to 2011. In contrast, it continued to rise at profit-based private orthopedic clinics."