Showing posts with label acromioplasty. Show all posts

Friday, December 23, 2022

Rotator cuff repair - is acromioplasty a good thing?

In his 1972 article , Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report, Charles Neer pointed out that "a characteristic ridge of proliferative spurs and excrescences on the undersurface of the anterior process [of the acromion] was seen frequently, apparently caused by repeated impingement of the rotator cuff and humeral head, with traction on the coracoacromial ligament" as shown in his figure

and his x-ray showing the traction spur in the coracoacromial ligament, but - notably - not encroaching on the rotator cuff space

Since this publication, numerous authors have tried to understand if these acromial changes are an effect or a cause of degenerative cuff disease.

The authors of Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder pointed out that acromioplasty for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. They sought high levels of evidence in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment:
(1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions,
(2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch,
(3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders,
(4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and
(5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch.

They found that these hypotheses were not supported by high levels of evidence.

Recently, the authors of Arthroscopic Rotator Cuff Repair with and without Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears Long-Term Outcomes of a Multicenter, Randomized Controlled Trial provided a longer term followup of their original study: Arthroscopic rotator cuff repair with and without acromioplasty in the treatment of full-thickness rotator cuff tears: a multicenter, randomized controlled trial with the goal of determining the long-term efficacy of subacromial decompression in patients with full-thickness rotator cuff tears.

Eighty-six patients were randomized in the original trial, with 31 of 45 from the group without acromioplasty and 25 of 41 from the acromioplasty group returning for long-term follow-up (mean: 11 years).

There was no significant difference in WORC scores between the groups with and without acromioplasty at the time of the long-term follow-up (p = 0.30).

Seven (16%) of the 45 patients in the group without acromioplasty and one (2%) of the initial 41 patients allocated to acromioplasty underwent or were recommended to have reoperation.

Comment: Two experienced surgeons performed all the surgeries. The distribution of primary cases and the distribution of revision cases between these two surgeons is not presented.

The authors stated, "Tears of ≤4 in size of one or more tendons were included," however the tear sizes in the acromioplasty and non acromioplasty groups are not presented. Furthermore, the initial tear sizes in the revised and unrevised shoulders are not presented. Thus is not clear whether the cuff pathology was worse in the shoulders with type 2 or type 3 acromions.

The integrity of the cuff / retears in the two groups were not routinely evaluated by MRI or ultrasound. The operative findings - particularly the integrity of the cuff and the degree of subacromial scarring- in the revised cases are not presented. Thus the cause of symptoms leading to repeat surgery is not clarified. This study does not provide robust evidence to support the concept that acromioplasty has "a protective effect on the rotator cuff repair in patients with an amorphous acromion."

A few additional thoughts in closing.

We need to continue to think about the observation of Codman (The Shoulder 1934, p24), that the articulation between the cuff and the coracoacromial arch is an "auxillilary joint" (see his drawing below), providing stability of the humeral head against upward directed loads...

....as well as his admonition (p 13), that "the coracoacromial ligament has an important duty [restraining the humeral head] and should not be thoughtlessly divided at any operation."

The articulation between the coracoacromial arch needs - as is the case for any articulation - to be smooth and to provide a broad contact area. As Neer pointed out, acromial spurs arise within the coracoacromial ligament. As such these spurs rarely encroach on the cuff. If there is a prominence to palpation of the curvature of the CA arch (which is uncommon), it can be conservatively smoothed with a bur without transection of the ligament or a major acromial resection.

Finally, some techniques of rotator cuff repair can disrupt the smoothness of the subacromial articulation by adding "top knots" that protrude from the surface of the repaired cuff.

In performing cuff repair, it may be best to position knots so that they do not rub against the CA arch.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Monday, June 27, 2022

Should surgeons continue to perform acromioplasty for impingement syndrome?

The concept of the "impingement syndrome" and its treatment by acromioplasty (aka subacromial decompression, SAD) were introduced 50 years ago (see this link).

In Published evidence relevant to the diagnosis of impingement syndrome of the shoulder the authors pointed out that surgery for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. They sought high levels of evidence (Level I and II studies) in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment:

(1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions,

(2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch,

(3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders,

(4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and

(5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch.

None of these hypotheses were supported by high levels of evidence.

They concluded that the concept of "impingement syndrome" was originally introduced to cover the full range of rotator cuff disorders, as it was recognized that rotator cuff tendinosis, partial tears, and complete tears could not be reliably differentiated by clinical signs alone. However, the current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated, so that the nonspecific diagnosis of "impingement syndrome" can be discarded in favor of specific diagnoses such as tendinosis, partial tears, and complete tears of the rotator cuff. The treatment for each these conditions requires careful, well-controlled clinical study.

The authors of On Patient Safety: Shoulder “Impingement”—Telling a SAD Story About Public Trust point out that acromioplasty quickly became one of the most commonly performed orthopaedic procedures; its usage increased five-fold between the 1980s and 2005 in the United States. However, evidence progressively accumulated that acromioplasty might be no more effective than physiotherapy. And the concept of "impingement syndrome" became recognized as a waste-basket term that included such diagnoses as bursitis, cuff tendinopathy, rotator cuff tear and biceps tendinitis.

The author and colleagues launched the Finnish Subacromial Impingement Arthroscopy Controlled

Trial (FIMPACT) in 2005. In Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial they concluded that arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy alone at 24 months after surgery. In reflection on this study, the British Medical Journal stated that "Subacromial decompression surgery should not be offered to patients with subacromial pain syndrome."

The author goes on to point out that acromioplasty remains one of the most frequently performed shoulder surgeries in the world. In considering why this might be, he suggests that surgeons trust their own “experiences” with an operation more than randomized clinical trials. While experience do matter, a surgeon's experiences suffers from follow-up that is short, does not include standardized data collection, and does not include the large percentage of patients in a surgical practice do not return for follow-up. This is in contrast to the FIMPACT trial that followed 81% of enrolled patients for 5 years and evaluated them using validated endpoints that matter to patients. Finally, the author points out that "procedures that carry greater risk (like shoulder surgery) should be superior to interventions with little or no risk (like shoulder exercises), and certainly superior to placebo interventions (such as the diagnostic arthroscopy performed in their controlled trial).

Another recent study, No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial randomly divided 140 patients into two groups: 1) supervised exercise program (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). While both groups were improved with respect to pain, disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days), no statistically significant differences were found in the patient-centred primary and secondary parameters between the two treatment groups. The authors concluded that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome.

An additional observation is that acromioplasty performed in the presence of a rotator cuff tear can give rise to anterosuperior escape and pseudoparalysis as shown here:

Because it is a major intervention with associated costs and risks, each surgical procedure requires solid evidence that supports clinically significant benefits in comparison to more benign approaches. Such support for acromioplasty does not appear to be present.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Sunday, December 13, 2020

Reverse total shoulder: does prior acromioplasty increase the risk of acromial fracture?

Incidence and risk factors of acromial fracture following reverse total shoulder arthroplasty

These authors sought to determine the incidence and risk factors for acromial fractures after reverse total shoulder (RTSA), comparing 29 patients with acromial fracture and 758 without this complication (3.7% incidence).

Acromial fractures were detected at a mean of 10.0 months (range 1-66) postoperatively. The occurrence of an acromial fracture was associated with a previous operation, deltoid lengthening, and low bone mineral density.

Eleven cases with postoperative acromial fractures had a history of a shoulder operation (rotator cuff repair with acromioplasty in 8, infection control surgery for pyogenic arthritis in 2, and total shoulder arthroplasty in 1).

Acromioplasty thins the acromion, making it more susceptible to fracture. Secondly, acromioplasty involves transection of the coracoacromial ligament, which, as shown in the article below, increases strain on the scapular spine.

Scapular Ring Preservation: Coracoacromial Ligament Transection Increases Scapular Spine Strains Following Reverse Total Shoulder Arthroplasty

Stating that the coracoacromial ligament (CAL) is often transacted during surgical exposure for reverse total shoulder arthroplasty (RSA), these authors hypothesized that the CAL contributes to the structural integrity of the “scapular ring” and that the transection of this ligament during RSA alters the scapular strain patterns in a way that may contribute to scapular fractures following this procedure.

They performed RSA on 8 cadaveric specimens and measured strains at the acromion and scapular spine before and after CAL section while a shoulder simulator positioned the joint in 0, 30, and 60 of glenohumeral abduction.

With the CAL intact, there was no significant difference between strain experienced by the acromion and scapular spine at 0, 30, and 60 of glenohumeral abduction.

CAL transection generated significantly increased strain in the scapular spine at all abduction angles compared with an intact CAL.

They concluded that the CAL is an important structure that completes the “scapular ring” and therefore serves to help distribute strain in a more normalized fashion.

In his 1934 book, E. A. Codman wrote prophetically, "The coracoacromial ligament has an important duty and should not be thoughtlessly divided at any operation."

We have not found it necessary to divide the CAL "at any operation." Not only is it a halyard stabilizing the scapular spine and acromion to the robust coracoid process, as suggest by this study, but it is also an essential element of the stabilizing coracoacromial arch.

which, when sacrificed, risks anterosuperior escape

which, in turn, is one of the reasons for performing a reverse total shoulder.

So, we agree with Codman, "The coracoacromial ligament has an important duty and should not be thoughtlessly divided at any operation."

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Saturday, May 16, 2020

Does the shape of the acromion matter?

Acromial morphology is not associated with rotator cuff tearing or repair healing

These authors sought to determine whether acromial morphology
(1) could be measured accurately on magnetic resonance images (MRIs) as compared to computed tomographs (CTs) as a gold standard,
(2) could be measured reliably on MRIs,
(3) differed between patients with rotator cuff tears (RCTs) and those without evidence of RCTs or glenohumeral osteoarthritis, and
(4) differed between patients with rotator cuff repairs (RCRs) that healed and those that did not.

They measured coronal, axial, and sagittal acromial tilt; acromial width, acromial anterior and posterior coverage, and glenoid version and inclination on MRI corrected into the plane of the glenoid.

They determined accuracy by comparison with CT via intraclass correlation coefficients (ICCs).
To determine reliability, these same measurements were made on MRI by 2 observers and ICCs calculated.
They compared these measurements between patients with a full-thickness RCT and patients aged >50 years without evidence of an RCT or glenohumeral osteoarthritis.
They then compared these measurements between those patients with healed RCRs and those with a retorn rotator cuff on MRI at least 1 year from RCR. Only those patients without tendon defects on postoperative MRIs were considered to be healed.

In a validation cohort of 30 patients with MRI and CT, all ICCs were greater than 0.86. In these patients, the inter-rater ICCs of the MRI measurements were >0.53.
In the RCT group of 110 patients, there was greater acromial width. Although the acromion was wider in shoulders with RCTs, the difference of 0.1 mm may have no clinical significance.
In these patients there was significantly less sagittal acromial tilt than in the comparison group of 107 patients.

At a mean follow-up of 24 months, 84 patients (76%) had healed RCRs.
There was no association between healing and any of the measured morphologic characteristics of the acromion.

The authors concluded that their findings call into question subacromial impingement due to native acromial morphology as a cause of rotator cuff tearing. Furthermore, acromial morphology, critical shoulder angle, and glenoid inclination were not associated with healing after RCR. As a result they concluded that this study did not support lateral acromioplasty.

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Comment: There is now substantial literature questioning the significance of the shape of the acromion in the pathogenesis of cuff tears.
In addition there is now substantial literature questioning the value to the patient of surgical modification of the acromion. See, for example, this link.

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Friday, January 31, 2020

The acromion is innocent

Subacromial Decompression Is Not Beneficial for the Management of Rotator Cuff Disease

These authors reviewed the available evidence on subacromial decompression (know by some as SAD). Even though evidence in support of this procedure is lacking, it is still one of the most common surgical procedures performed on the shoulder. Their conclusions are listed below.

» Currently, the 2 most common indications for performing a subacromial decompression are subacromial pain syndrome refractory to nonoperative treatment and repair of rotator cuff tears.
» Multiple, high-quality randomized controlled trials showed that subacromial decompression did not provide improvements in pain, function, or quality of life compared with a placebo surgical procedure or other conservative treatments for patients with subacromial pain syndrome.
» Similarly, several randomized controlled trials failed to prove any functional or structural advantage when performing rotator cuff repairs with or without subacromial decompression.
» Imaging studies showed that subacromial decompression did not prevent the development or progression of rotator cuff tears. Moreover, similar retear rates were reported between patients in which rotator cuff repairs were performed with or without subacromial decompression.
» In conclusion, subacromial decompression did not provide any clinical or structurally substantial benefit for the treatment of subacromial pain syndrome or the surgical repair of rotator cuff tears.

This review supports the findings published a decade ago: Published evidence relevant to the diagnosis of impingement syndrome of the shoulder. That abstract is reproduced below

BACKGROUND: Acromioplasty for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. This investigation sought high levels of evidence in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment.

METHODS: We conducted a systematic review of articles relevant to the following hypotheses: (1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions, (2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch, (3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders, (4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and (5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch. Three of the authors independently reviewed each article and determined the type of study, the level of evidence, and whether it supported the concept of the impingement syndrome. Articles with level-III or IV evidence were excluded from the final analysis.

RESULTS: These hypotheses were not supported by high levels of evidence.

CONCLUSIONS: The concept of impingement syndrome was originally introduced to cover the full range of rotator cuff disorders, as it was recognized that rotator cuff tendinosis, partial tears, and complete tears could not be reliably differentiated by clinical signs alone. The current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated. Nonoperative and operative treatments are currently being used for the different rotator cuff abnormalities. Future clinical investigations can now focus on the indications for and the outcome of treatments for the specific rotator cuff diagnoses. It may be time to replace the nonspecific diagnosis of so-called impingement syndrome by using modern methods to differentiate tendinosis, partial tears, and complete tears of the rotator cuff.

Comment: The coracoacromial arch is an important stabilizer of the proximal humerus against superiorly directed loads. Contact between the cuff and the arc is normal. Sacrifice of this structure can lead to anterosuperior escape and pseudoparalysis.

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Saturday, March 2, 2019

Arthroscopic subacromial decompression - is it of value to the patient?

Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial

These authors assessed the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy, a placebo surgical intervention, and with a non-operative alternative, exercise therapy using a multi center randomised, double blind, sham controlled trial.

The study included 210 patients with symptoms consistent with shoulder impingement syndrome, enrolled from 1 February 2005 with two year follow-up completed by 25 June 2015.

Main outcome measures were shoulder pain at rest and on arm activity (visual analogue scale (VAS) from 0 to 100, with 0 denoting no pain), at 24 months. The threshold for minimal clinically important difference was set at 15.

In the primary intention to treat analysis (ASD versus diagnostic arthroscopy), no clinically relevant between group differences were seen in the two primary outcomes at 24 months (mean change for ASD 36.0 at rest and 55.4 on activity; for diagnostic arthroscopy 31.4 at rest and 47.5 on activity). The observed mean difference between groups (ASD minus diagnostic arthroscopy) in pain VAS were −4.6 (95% confidence interval −11.3 to 2.1) points (P=0.18) at rest and −9.0 (−18.1 to 0.2) points (P=0.054) on arm activity. No between group differences were seen between the ASD and diagnostic arthroscopy groups in the secondary outcomes or adverse events.

In the secondary comparison (ASD versus exercise therapy), statistically significant differences were found in favour of ASD in the two primary outcomes at 24 months in both VAS at rest (−7.5, −14.0 to −1.0, points; P=0.023) and VAS on arm activity (−12.0, −20.9 to −3.2, points; P=0.008), but the mean differences between groups did not exceed the pre-specified minimal clinically important difference. Of note, this ASD versus exercise therapy comparison is not only confounded by lack of blinding but also likely to be biased in favour of ASD owing to the selective removal of patients with likely poor outcome from the ASD group, without comparable exclusions from the exercise therapy group.

In this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over the "sham" procedure of diagnostic arthroscopy at 24 months.

The results of this study are consistent with that of another recent randomized controlled trial:

Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial.

These authors point out that arthroscopic sub-acromial decompression (decompressing the sub-acromial space by removing bone spurs and soft tissue arthroscopically) is a common surgery for subacromial shoulder pain, but its effectiveness is uncertain.

They performed aa 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 programme that included exercise therapy and at least one steroid injection. Exclusion criteria included a full-thickness torn rotator cuff. They randomly assigned participants (1:1:1) to arthroscopic subacromial decompression, investigational arthroscopy only, or no treatment (attendance of one reassessment appointment with a specialist shoulder clinician 3 months after study entry, but no intervention). Arthroscopy only was a placebo as the essential surgical element (bone and soft tissue removal) was omitted.

Patients were followed up at 6 months and 1 year after randomisation; surgeons coordinated their waiting lists to schedule surgeries as close as possible to randomisation. The primary outcome was the Oxford Shoulder Score (0 [worst] to 48 [best]) at 6 months, analysed by intention to treat.

They randomly assigned 313 patients to treatment groups (106 to decompression surgery, 103 to arthroscopy only, and 104 to no treatment). 24 [23%], 43 [42%], and 12 [12%] of the decompression, arthroscopy only, and no treatment groups, respectively, did not receive their assigned treatment by 6 months. 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.

Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months (decompression mean 32·7 points [SD 11·6] vs arthroscopy mean 34·2 points [9·2]; mean difference -1·3 points (95% CI -3·9 to 1·3, p=0·3141). Both surgical groups showed a small benefit over no treatment (mean 29·4 points [SD 11·9], mean difference vs decompression 2·8 points [95% CI 0·5-5·2], p=0·0186; mean difference vs arthroscopy 4·2 [1·8-6·6], p=0·0014) but these differences were not clinically important. There were six study-related complications that were all frozen shoulders (in two patients in each group).

They concluded that the 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. They state that their findings question the value of this operation for these indications, and that this should be communicated to patients during the shared treatment decision-making process.

Comment: These two well done randomized trials do not demonstrate value to the patient for one of the most commonly performed shoulder surgeries: the subacromial decompression. Discussers of these papers have come to some dramatic conclusions:

"Based on these results, we should question the current line of treatment according to which patients with shoulder pain attributed to shoulder impingement are treated with decompression surgery, as it seems clear that instead of surgery, the treatment of such patients should hinge on nonoperative means," Järvinen states. "By ceasing the procedures which have proven ineffective, we would avoid performing hundreds of thousands useless surgeries every year in the world," Järvinen points out. "Fortunately, there seems to be light at the end of the tunnel as the NHS in England just released a statement that they will start restricting funding for 'unnecessary procedures' and the list includes subacromial decompression. We applaud this initiative and encourage other countries to follow this lead."

"We have to spend taxpayers' money responsibly. If we are spending money on procedures that are not effective, that money is deprived from treatments that are clinically effective and would provide benefits to patients. One component in becoming more efficient is to make sure we are not undertaking unnecessary procedures,"

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Sunday, January 14, 2018

Rotator cuff failure is often bilateral, acromioplasty may increase the risk of arthritis

Patients with a long-standing cuff tear in one shoulder have high rates of contralateral cuff tears: a study of patients with arthroscopically verified cuff tears 22 years ago

These authors identified 61 patients with 38 partial and 23 full-thickness tears of one shoulder at arthroscopy and examined them with bilateral radiographs, ultrasound, and the Constant-Murley score at a mean of 22 years (range, 21-25 years) after arthroscopy.

The overall rate of full-thickness tears in the contralateral shoulder was 50.8%.

With a full-thickness tear in the index shoulder, the frequency of contralateral full-thickness tears was even higher (71.8%). The number of tendons with full-thickness tear involvement in 1 shoulder was a risk factor for having a contralateral cuff tear.

90% of the patients with CTA (defined as Hamada grade ≥ 2) had a contralateral full thickness tear.

20% of patients with CTA in the index shoulder also had arthropathy in the contralateral shoulder.

CTA changes were more common in patients with full-thickness tear and a previous acromioplasty (P < .001).

They concluded that patients with long-standing cuff tears have high rates of contralateral cuff tears. The severity of the condition is strongly correlated between the shoulders. Patients with full-thickness tears and a previous acromioplasty had a significantly higher frequency of CTA than patients with cuff tears who had not undergone a previous acromioplasty.

Comment: The multivariate analysis showed that the only significant factor for contralateral tear was the number of tendons with full thickness tears in the index shoulder at the time of followup. I.e. a bigger tear on one side predicted a tear on the other side.

It would have been of interest to see a multivariate analysis of the potential factors associated with cuff tear arthropathy on the index and on the contralateral shoulders.

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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).

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."

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Tuesday, October 24, 2017

More thoughts on the rotator cuff

In followup to the prior post (see this link), we were posed two additional questions. Here they are along with our thoughts.

1. What is the role of partial acromioplasty during surgery for rotator cuff disease?

The rationale for an acromioplasty is not established.

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”.[1] When this advice is ignored – especially in the presence of cuff deficiency - the shoulder can be destabilized against superiorly directly loads risking anterosuperior escape.

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”[2] , in other words the changes in the acromion were caused by the cuff. Establishment of causation requires the application of criteria originally described by Hill et al in demonstrating the causation of scrotal cancer in chimney sweeps, and recently used to demonstrate the causation of chondrolysis by pain pumps.[3] When we see a certain acromial configuration in patients with cuff lesions, we must ask, “which is the chicken and which is the egg or are they both products of genetics and aging?”

The diagnosis of ‘impingement syndrome’ is difficult to pin down.[4] [5] Authors of a recent article[6] summarizing the published evidence relevant to the diagnosis of ‘impingement syndrome’ of the shoulder 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.

Our practice is to preserve the coracoacromial arch (call us ‘Codmanists’ if you will), finding that its surgical compromise is not necessary to perform the necessary cuff surgery and finding no reliable evidence that altering the coracoacromial arch changes the outcome for the patient.

2. Regarding surgery for rotator cuff disease, what do you perceive to be the major gaps in our evidence base, and how do you make treatment decisions in light of these gaps?

The gap is lack of evidence.

For each of our patients we must ask, was our treatment successful and “if not why not?” [7] so that our treatment of the next patient will be better informed.

We are humbled in the knowledge that over ¼ million cuff repairs are done each year[8] while we have such a limited understanding of how much patients benefit from this procedure in comparison to other management approaches for cuff pathology. The recent American Academy of Orthopaedic Surgeons clinical practice guidelines on optimizing the management of rotator cuff problems[9] provide no high-level evidence to guide treatment; 22 of 25 statements were inconclusive or based on weak evidence or opinion. A recent Cochrane review[10] on the rotator cuff concluded that (1) surgery may not lead to any difference in pain compared with different exercise programs, (2) arthroscopic surgery may not lead to any difference in outcome in the long run compared with open surgery, 3) there was not enough information to tell whether surgery would make a difference in the ability to use the shoulder normally, the quality of life, the shoulder's range of motion, the strength, the chance that the symptoms might come back, the time it takes to return to work or sports and whether people are satisfied with surgery.

Thus, rather than asking, “Why is it that despite the reported success of nonoperative treatment for cuff tears, arthroscopic rotator cuff repair is one of the most commonly performed procedures in the field of orthopedic surgery?,” one might ask “why is it that less than 5% of people with cuff tears undergo surgery each year?[11]”

As pointed out recently[12], “a patient's decision to undergo surgery is influenced more by low expectations regarding the effectiveness of physical therapy than by patient symptoms or anatomic features of the rotator cuff tear”. These expectations are, of course, set in large part by the information they get from the health care provider they visit, be it therapist or surgeon. As one wag pointed out, what we get depends on whether we visit the patisserie or the charcuterie.

We have many gaps that need to be bridged before we can come up with evidence-based practice guidelines. It is evident that the evidence we need will only come from a large database that includes basic data on individual patients from the full range of providers (‘consensus panels’ cannot provide evidence). Such a database will be enabled in large part by the answers to these questions:

(1) How can we capture data on the largest and most diverse sample of patients with cuff disease?

(2)What is the most practical way to characterize a patient with a cuff tear, i.e. what is the minimal data set we need to include the patient in a database that will enable us to compare the natural history and treatment outcomes for individual patients[13]?

(3)In such a database, how can one be sure that the breadth of possible treatments (including non-repair surgery[14]) are represented and that the type of treatment is characterized in a manner that enables analysis?

(4)In such a database, how will the preoperative and postoperative condition of the shoulder be documented?

If we are to derive robust practice guidelines for the management of rotator cuff conditions we will need ‘big data’ to avoid the trap of ‘fragility of statistically significant findings’ identified by Bhandari et al[15]. That is the gap we need to fill.