Which rotator cuff repairs fail?

Anteroposterior tear size, age, hospital, and case number are important predictors of repair integrity: an analysis of 1962 consecutive arthroscopic single-row rotator cuff repairs

These authors point out that retear and nonhealing of a surgically repaired rotator cuff are common. They aimed to determine the relationship between preoperative and intraoperative factors and retear rate following rotator cuff repair using  data from 1962 consecutive patients who underwent a primary arthroscopic single-row rotator cuff repair performed by an individual surgeon from 2007 through 2018 and postoperatively returned for 6-month follow-up ultrasonography.

The mean patient age at surgery was 59 years. 1156 of the tears were  full thickness whereas 806 were partial thickness.

The mean anteroposterior tear length was 1.8 cm, and the mean mediolateral tear length was 1.6 cm  The mean value of their resultant product (tear size area) was 3.7  cm2.

On average, 2 suture anchors were used, and repairs required 20 minutes.

1583 repairs were performed in a private hospital whereas 107 were performed in a public hospital.

At 6-month follow-up, 1691 rotator cuff repairs were found to be intact whereas 271 (14%)  had retorn or not healed.

Patients who had retears at 6 months were more likely to be men, to be older, and to present with a full-thickness tear rather than partial-thickness tear. Their repairs required more suture anchors and a longer operative time. Intraoperatively, significantly greater anteroposterior and mediolateral tear lengths were found in the retear group than in the intact group. Consequently, the mean intraoperative tear size area was approximately 2.5 times greater among retears as compared with intact tendons.

The data indicated that following rotator cuff repair, there was a 4-fold increase in the retear rate as the anteroposterior tear size increased from 1 cm to 3 cm; a 8-fold decrease when comparing case number 1000 with case number 3000; a 2-fold increase as patient age increased from 50 years to 70 years; and a 3-fold increase when comparing surgery performed in a public hospital vs. a private hospital.

Case number was used as a proxy measure for overall progress over time in the rotator cuff repair and rehabilitation process, encompassing factors including surgical experience and rehabilitation experience. An increased case number may have reduced retears via factors including increased surgical experience and improved, less aggressive rehabilitation protocols throughout the course of the study.

With respect to the role of hospital type in rotator cuff retear the authors suggest that the effect may be explained by factors including disparate patient factors such as socioeconomic status between the 2 groups or younger surgeons assisting in rotator cuff repairs under the supervision of the senior author in the public hospital. Furthermore, the private hospital may have had superior operating room equipment in addition to more experienced staff that may have led to lower retear rates; moreover, a preoperative rehabilitation education clinic was freely available to patients treated in the private hospital.

Comment: This is a large study with carefully analyzed data from a high volume Australian shoulder surgeon. The tears repaired in this series were small (average AP dimension <2cm) and included a substantial number of partial thickness tears. AP tear size, hospital experience, patient age and hospital type emerged as the most important factors associated with retear. The relationship of repair integrity to patient reported outcome was not explored in this study.

How you can support research in shoulder surgery Click on this link.

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 total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

Many rotator cuff tears are a function of aging - how do you treat that?

A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age

These authors reviewed the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with advancing age.  Their search terms included cuff degeneration, tear, disruption, perforation, pathologic change, defect, lesion, or abnormality. They assessed the prevalence of cuff tear abilities in 4 groups: (1) asymptomatic patients, (2) general population (including cadavers), (3) symptomatic patients, and (4) patients after shoulder dislocation.Thirty studies including 6112 shoulders met their criteria.

The prevalence of abnormalities increased with age for each of the groups.

Comment:  A key comment in this article is that "Atraumatic rotator cuff defects are commonly referred to as tears, but if rotator cuff thinning is part of the normal aging process, the word tear which implies damage in need of repair may be inappropriate." We have previously posted on  cuff tear versus cuff wear.

The authors conclude that the prevalence of rotator cuff abnormalities in asymptomatic people is high enough for rotator cuff tendon failure to be considered a common aspect of normal human aging and not necessarily an indication for surgery. These results also point to the increasing frailty of the cuff with age, a characteristic that is not changed by rotator cuff repair surgery.

Against this background, it is important to consider the relative advantages and disadvantages of  non-opeartive, non-repair surgery and surgical repair attempt for each patient found to have a cuff tendon defect.

Our approach to the rotator cuff is summarized here. 

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Management of rotator cuff tears

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Optimizing the Management of Full-Thickness Rotator Cuff Tears


This article proposes a formula for determining the appropriateness of different approaches to the patient with a rotator cuff defect using "appropriate use criteria".

Importantly the authors emphasize some of the 4Ps.

The problem is characterized in terms of the tear size, retraction, and atrophy/fatty infiltration as well as the severity of pain
The patient is characterized in terms of
 - the American Society of Anesthesiologist classification of the amount of systemic disease,
 -  factors that negatively affect healing (for example: diabetes, obesity, osteoporosis, prior infection, advanced age, smoking, multiple cortisone injections, use of predisone or immunosupressive drugs, and Parkinson's disease)
 - factors that negatively affect outcome (for example: worker's compensation, litigation, substance abuse, psychiatric disorders)
The procedures are characterized as nonsurgical, non-repair surgery, repair surgery, reconstruction with a patch or tendon transfer, and arthroplasty.

What is missing from these recipes is (1) consideration of the degree of trauma that caused the tear, (2) the chronicity of the tear, and (3) the recognition that cuff defects often present as weakness rather than pain. A 40 year old with acute shoulder weakness after a major fall within the last week resulting in a supraspinatus and infraspinatus tear usually deserves acute repair, whereas a 70 year old with chronic shoulder symptoms associated with the same size tear without a history of trauma deserves a good try at non-operative management, recognizing that attempted repair is not likely to durably restore the integrity of the cuff. If non-operative management is unsuccessful, the surgical options are determined by the degree of active motion, the stability of the joint, the presence or absence of arthritis, and the functional needs of the patient along with risk factors.

The companion article, AAOS Appropriate Use Criteria: Optimizing the Management of Full-Thickness Rotator Cuff Tears, further demonstrates the difficulty of applying the 'appropriate use criteria. Case 2 example 3 is a 66 woman with diabetes with chronic refractory pain, active motion limited to 45 degrees, and a large supra+infraspinatus tear retracted to the level of the glenoid and fatty infiltration, who smokes a pack of cigarettes per day. The AUC recommends 'reconstruction', defined as 'an augmented repair with a patch or tendon transfer'.   The evidence is that neither a patch or a tendon transfer would yield a satisfactory result for this woman: individuals who smoke and who have diabetes are likely to have difficulty healing a patch or tendon transfer.

For our approach see "when to repair". and more about when to repair. It is important to distinguish cuff wear from cuff tear: not all cuff defects have the same quality of surrounding tissue.

Click here to see the new Rotator Cuff Book

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Rotator cuff tears - getting better without surgery

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study

The authors indicate that 10% of Americans aged over 60 years, or 6 million individuals, have full-thickness rotator cuff tears. Furthermore, only 250,000 rotator cuff repairs are performed each year. As we've pointed out before the average cost of a cuff repair exceeds 10,000, so that the total 'bill' for cuff repair surgery may be $2,500,000,000. As we have also indicated in previous posts, many surgical attempts to repair a rotator cuff defect do not succeed in re-establishing an intact tendon, yet patients may be improved after the surgery and post surgical rehabilitation.

This paper asks the interesting question, 'what if one did the rehabilitation without the surgery?'

They assessed the effectiveness of a specific nonoperative physical therapy program in treating 452 patients with atraumatic full-thickness rotator cuff tears. The average patient age was 63 years and the gender distribution was essentially equal. The authors were careful to exclude the patient with a rotator cuff tear after a major injury, in that most of us believe that an acute traumatic rotator cuff tear, especially in active individuals merits consideration for surgical repair. The program consisted of simple stretching and gentle strengthening exercises, similar to those shown here, that used no special equipment. Patients were allowed to opt for surgery after 6 weeks if they felt the exercise program was ineffective. Of interest is the observation that almost 25% of the patients had 'had therapy' prior to enrollment in the study. 70% of the shoulders had supraspinatus only tears. One third had tendon retraction to the mid humeral head.

The authors found that patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months. Highly statistically significant improvements were seen in the ASES, WORC, SANE and SF12 PCS patient self-assessment scores. Of the 319 patients available for two year followup, only 26% had had surgery.

Another recent article compared formal with home therapy and found essentially no difference in their effectiveness.

While the authors did not report the cost of the rehabilitation program in comparison to the likely cost of treating all of the patients with surgery, it is likely that in this set of 452 individuals over $3 million was saved by avoiding surgery in three out of four patients. Furthermore, the patients with successful non-operative management were spared the risks of surgery and the associated post operative 'down time'.

This paper presents a strong argument for a trial of at least 6 weeks of simple rehabilitation for individuals with atraumatic rotator cuff tears.

Should the patient elect to proceed with surgery, the rotator cuff may not be securely reparable. For that reason, we present this information to the patient for their preoperative consideration.

A final comment: tendons that tear without trauma ("atraumatic" as so many are) are likely to be intrinsically weak - surgical repair attempts of these tendons are likely to be frustrated by suture tension overload leading to pull-through of the sutures.

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Intraoperative Determinants of Rotator Cuff Repair Integrity

Intraoperative Determinants of Rotator Cuff Repair Integrity

This is an individual surgeon experience with 500 arthroscopic cuff repairs evaluated for integrity by ultrasound at 6 months. The best predictor of cuff repair integrity at followup was the size of the tear being repaired as shown in the chart below. Patient age was the next best predictor of integrity. Tendon quality and mobility and repair quality were much less influential on the result.

This study provides valuable information that we can use in our preoperative discussions with our patients, weighing out the different possible approaches for management of cuff tears.  Important to remember that 6 month is early in the recovery of cuff repairs - it is likely that the failure rate would be higher with longer periods of followup.

It would have been more informative if the authors had included clinical outcomes along with their integrity data so the relative influence of integrity on clinical outcome could be determined.

It would have also been of interest to know whether the acuity of the tear had in influence on the outcome (i.e. is the prognosis for acute large tears the same as for chronic large tears?).

Nevertheless, the authors are commended on a robust study design and analysis: "During the study period (between January 2006 and February 2009), 722 rotator cuff repairs were performed. Of these, 667 repairs were performed using the Opus Magnum knotless anchor. A total of 167 patients were excluded on the basis of the exclusion criteria: 14 patients were excluded because of previous shoulder surgery or redo of rotator cuff repair, 22 were excluded for incomplete or partial cuff repairs, 38 were excluded for moderate to severe osteoarthritis of the shoulder, 10 were excluded for isolated subscapularis repair, 1 patient was excluded because of a greater tuberosity fracture, and 82 patients were excluded because they were lost to follow-up or no ultrasound was performed at 6 months. The remaining 500 patients form the study cohort."

As we've suggested in a previous post, so much of what influences the outcome of cuff surgery can be determined without worrying about fatty infiltration on MRI.

We also note that these 6 month retear rates are virtually identical to those reported with other methods of repair, so that the tear size rather than the repair method may be the key determinant of the integrity outcome.

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Arthroscopic repair of large rotator cuff tears using the double-row technique: an analysis of surgeon experience on efficiency and outcomes JSES

Arthroscopic repair of large rotator cuff tears using the double-row technique: an analysis of surgeon experience on efficiency and outcomes.

This study set out to be a learning curve study in which surgeon experience was related to outcome. An ideal example of such a study can was shown in this previous post, a study in which surgeon experience was treated as a parametric variable and the outcome (in that case complications) was also treated as a parametric variable. In this study, however, surgeon experience was arbitrarily divided into two groups: the first 18 months of practice and afterwards. Such an arbitrary division runs the risk of missing the opportunity to answer the question, "how many cases does it take to achieve a certain level of proficiency?" See this post, for example.

There are essentially three types of learning curves (see below). 

(1) - the progressive, shown by the blue line (the more you do the better you get), (2) the threshold, shown by the red line (after so many you achieve mastery level and do not improve much beyond that) and (3) the non effect, shown by the green line (the result is unrelated to the number you've done).

There is no need for an arbitrary division of the surgeon's experience into two categories as was done in this paper.

The authors of this paper collected the data and had the opportunity to do an interesting study. They collected data on patient age, gender, body mass index, smoking, diabetes, acuity of tear and tear size, as well as surgeon experience. Wouldn't it be wonderful if they did a multivariate analysis of these variables on the improvement patients experienced after their surgery? If they threw in data on the integrity of the repair at followup, it would be even better.

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Long-term follow-up of cases of rotator cuff tear treated conservatively JSES

Rotator cuff tear

JSES published a study on the Long-term follow-up of cases of rotator cuff tear treated conservatively. Between 1996 and 1999, the authors offered non-operative treatment to 104 consecutive patients (107 shoulders) diagnosed by MRI or arthrogram as having rotator cuff tears. Patients were informed that they could have surgery if their symptoms continued. Non-operative management included injections, medications and physical therapy continued until the patient was satisfied. Three patients had cuff repair for persistent limiting symptoms. Long term followup was available in 2009 on 43 shoulders, of which 56% had no pain, 33% had slight pain, and 12% had pain during activities of daily living. Patients with poorer results tended to be younger than those with better results.

This article was highlighted in a recent email from an orthopaedic surgeon colleague: "As you may recall, I have a irreparable rotator cuff tear (RCT). I followed your advice and now my right shoulder is essentially asymptomatic. Yesterday I skied 19000 vertical feet—19 Xs up and down XXX —with no shoulder probs. Several months ago J. Shoulder Elbow had a commentary on Dr. Codman, publishing his first 2 rotator cuff repair op. reports. I was fascinated to read that Codman concluded that the massive tears he found in the hod carrier and Irish washerwoman had been present for years without significant functional impairment. A recent article from Japan (J. Shoulder Elbow (2012), 491-494 indicates that the great majority of pts they followed had no significant sx or impairment with unrepaired RCTs. I have done lots of Independent Medical Evaluations on workers who had rotator cuff tears of various severity who had open or arthroscopic repairs—the result is usually the same—some residual pain which limits them with overhead work and a ratable impairment in the range of 10% to 25% of the upper extremity due to postoperative stiffness. My question is why, especially in the worker’s comp setting, does a MRA showing a tear automatically result in an attempted surgical repair? Am I missing something? Are there good reasons to repair RCTs surgically? What are the indications other than a positive MRA?"

The principal value of this article is that it demonstrates that rotator cuff tear in and of itself need not be an indication for surgery. While the Journal listed this as a Level II prognostic study, we really don't have enough data to use the data prognostically. What would have been most helpful would be to know more about the size and acuity of the cuff tears as well as the shoulder function at the time they presented. It would also be important to know more about the fate of the 50+ shoulders that were not included in the follow-up for a variety of reasons. 

It seems important that several elements need to be included in any study of rotator cuff treatment:

(1) patient age

(2) whether the tear is acute or chronic

(3) the comfort and function of the shoulder

As we've posted before, other factors are important in determining if the rotator cuff is repairable.

Whether or not the patient should have a repair depends not only on the repairability of the tear, but also on the nature and severity of the problems the patient is having with their shoulder. In many cases, when non-operative management of chronic cuff tears is insufficiently effective, we have found that a 'smooth and move procedure' is helpful, without the need for the extensive recovery perior necessary to protect a repaired cuff tear.

In summary, we encourage young, non-smoking individuals with symptomatic, repairable acute rotator cuff tears to consider a prompt cuff repair so that they have the optimal chance of regaining their strength. Individuals with chronic tears have time to try non-operative management, including stretching, strengthening of the deltoid and residual cuff muscles, and mild anti-inflammatory analgesics. If this non-operative program fails to give the desired improvement, the pros and cons of repair vs. smooth and move are reviewed with the patient.

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The impact of preoperative smoking habits on the results of rotator cuff repair. JSES

The January JSES publishes: The impact of preoperative smoking habit on rotator cuff tear: cigarette smoking influences rotator cuff tear sizes. This article showed that the presence and amount of cigarette smoking correlated with the size of the cuff tear.

A previous article, The impact of preoperative smoking habits on the results of rotator cuff repair, demonstrated that smokers had inferior outcomes from cuff repair.

There may be other effects of smoking as we mentioned in a previous post.

For these reasons, we are reluctant to perform cuff repair on individuals who smoke or who have a substantial smoking history.

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Efficacy of Autologous Platelet-Rich Plasma Use for Orthopaedic Indications JBJS

Two recent JBJS publications, Efficacy of Autologous Platelet-Rich Plasma Use for Orthopaedic Indications: A Meta-Analysis and Platelet-Rich Plasma Differs According to Preparation Method and Human Variability are relevant to the rapidly increasing interest in PRP for the management of musculoskeletal disorders. In short, the first article reports that in spite of 33 high quality studies, there remains uncertainty about the effectiveness of PRP in the management of disorders such as rotator cuff injuries - basically, the results were just too variable to determine if there was or was not a beneficial effect.

The second article indicates that the different preparations of PRP are quite variable.

We'll have to continue to observe this evolving area to see what sorts out as more high quality studies with the different preparations become available. 

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American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: Optimizing the Management of Rotator Cuff Problems

The Academy has published guidelines for the clinical management of rotator cuff problems.

What is discouraging is the lack of quality evidence in support of treatment for this most common of shoulder disorders:

"1. Full Thickness Tears and Asymptomatic Patients. In the absence of reliable evidence, it is the opinion of the work group that surgery not be performed for asymptomatic, full thickness rotator cuff tears.
Strength of Recommendation: Consensus opinion of the panel

2. Full Thickness Tears and Symptomatic Patients. Rotator cuff repair is an option for patients with chronic, symptomatic full thickness tears.
Strength of Recommendation: Weak

3. a. Rotator Cuff Tears and Exercise a. We cannot recommend for or against exercise programs (supervised or unsupervised) for patients with rotator cuff tears.
Strength of Recommendation: Inconclusive

3. b. Rotator Cuff Tears and Corticosteroid Injections. We cannot recommend for or against subacromial injections for patients with rotator cuff tears.
Strength of Recommendation: Inconclusive

3. c. Rotator Cuff Tears and NSAIDS, Activity Modification, Ice, Heat, Iontophoresis, Massage, T.E.N.S., PEMF, and Phonophoresis. We cannot recommend for or against the use of NSAIDS, activity modification, ice, heat, iontophoresis, massage, Transcutaneous Electrical Nerve Stimulation (TENS), Pulsed Electromagnetic Field (PEMF), or phonophoresis (ultrasound) for nonoperative management of rotator cuff tears.
Strength of Recommendation: Inconclusive

4. a. Rotator Cuff Related Symptoms and Exercise or Nonsteroidal Anti-Inflammatory Medication. We suggest that patients who have rotator cuff-related symptoms in the absence of a full thickness tear be initially treated non-operatively using exercise and/or non-steroidal anti-inflammatory drugs.
Strength of Recommendation: Moderate

4. b. We cannot recommend for or against subacromial corticosteroid injection or Pulsed Electromagnetic Field (PEMF) in the treatment of rotator cuff-related symptoms in the absence of a full thickness tear.
Strength of Recommendation: Inconclusive

4. c. Rotator Cuff Related Symptoms and Iontophoresis, Phonophoresis, Transcutaneous electrical nerve stimulation (TENS), ice, heat, massage or activity modification. We cannot recommend for or against the use of iontophoresis, phonophoresis, transcutaneous Electrical Nerve Stimulation (TENS), ice, heat, massage, or activity modification for patients who have rotator cuff related symptoms in the absence of a full thickness tear.
Strength of Recommendation: Inconclusive

5. Acute Traumatic Rotator Cuff Tears and Surgery  Early surgical repair after acute injury is an option for patients with a rotator cuff tear.
Strength of Recommendation: Weak

6. Perioperative Interventions –Corticosteroid Injections/NSAIDS. We cannot recommend for or against the use of perioperative subacromial corticosteroid injections or non-steroidal anti-inflammatory medications in patients undergoing rotator cuff surgery.
Strength of Recommendation: Inconclusive

7. a. Confounding factors – Age, Atrophy/Fatty Degeneration and Worker’s Compensation Status. It is an option for physicians to advise patients that the following factors correlate with less favorable outcomes after rotator cuff surgery:  Increasing Age, MRI Tear Characteristics, Worker’s Compensation Status
Strength of Recommendation: Increasing Age: Weak,

7. b. Confounding Factors - Diabetes, Co-morbidities, Smoking, Infection, and Cervical Disease. We cannot recommend for or against advising patients in regard to the following factors related to rotator cuff surgery: Diabetes, Co-morbidities, Smoking, Prior Shoulder Infection, Cervical Disease
Strength of Recommendation: Inconclusive

8. Surgery - Acromioplasty. We suggest that routine acromioplasty is not required at the time of rotator cuff repair.
Strength of Recommendation: Moderate**** See below

9. Surgery – Partial Rotator Cuff Repair, Debridement, or muscle transfers for patients with irreparable rotator cuff tears when surgery is indicated. It is an option to perform partial rotator cuff repair, debridement, or muscle transfers for patients with irreparable rotator cuff tears when surgery is indicated.
Strength of recommendation: Weak

10. a. Surgery – Tendon to Bone Healing. It is an option for surgeons to attempt to achieve tendon to bone healing of the cuff in all patients undergoing rotator cuff repair.
Strength of Recommendation: Weak

10. b. Surgery - Suture Anchors and Bone Tunnels We cannot recommend for or against the preferential use of suture anchors versus bone tunnels for repair of full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive

10. c. We cannot recommend for or against a specific technique (arthroscopic, mini-open or open repair) when surgery is indicated for full thickness rotator cuff tears.

Strength of Recommendation: Inconclusive 

11. a. Surgery - Non-Crosslinked, Porcine Small Intestine Submucosal Xenografts. We suggest surgeons not use a non-crosslinked, porcine small intestine submucosal xenograft patch to treat patients with rotator cuff tears.
Strength of Recommendation: Moderate

11. b. Surgery - Allografts and Xenografts. We cannot recommend for or against the use of soft tissue allografts or other xenografts to treat patients with rotator cuff tears.
Strength of Recommendation: Inconclusive

12. Post-Operative Treatment - Cold Therapy. In the absence of reliable evidence, it is the opinion of the work group that local cold therapy is beneficial to relieve pain after rotator cuff surgery.
Strength of Recommendation: Consensus opinion of the panel

13. a. Post-Operative – sling, shoulder immobilizer, abduction pillow, or abduction braceWe cannot recommend for or against the preferential use of an abduction pillow versus a standard sling after rotator cuff repair.
Strength of Recommendation: Inconclusive

13. b. Post-Operative Rehabilitation – Range of Motion Exercises. We cannot recommend for or against a specific time frame of shoulder immobilization without range of motion exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive

13. c. Post-Operative Rehabilitation – Active Resistance Exercises. We cannot recommend for or against a specific time interval prior to initiation of active resistance exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive

13. d. Post-Operative Rehabilitation – Home Based Exercise and Facility Based Rehabilitation. We cannot recommend for or against home-based exercise programs versus facility-based rehabilitation after rotator cuff surgery.
Strength of Recommendation: Inconclusive

14. Post-Operative - Infusion Catheters. We cannot recommend for or against the use of an indwelling subacromial infusion catheter for pain management after rotator cuff repair.
Strength of Recommendation: Inconclusive"

****From the body of the report (q.v.) we find that this is the statement with the highest level of evidence (Level II). These recommendations are consistent with our previous posts and publications.  "Acromioplasty and release of the coracoacromial ligament is often included as part of a rotator cuff repair. Theoretical benefits of an acromioplasty in the setting of a rotator cuff repair include increasing the subacromial space available to facilitate the repair and also relieving extrinsic compression on the repair after completion. Despite these theoretical benefits, one quality study101 suggests that an anterior acromioplasty has no effect on final outcomes after rotator cuff repair. Two studies89, 81 reviewed the results of removing acromial bone (Bigliani type II and III acromions) and did not find any benefit in postoperative functional results.

One Level II randomized prospective study89 performed a comparison of 47 patients treated with an arthroscopic rotator cuff repair plus an associated anterior acromioplasty and coracoacromial ligament release with 46 patients who underwent rotator cuff repair alone. All patients had isolated supraspinatus rotator cuff tears with Bigliani type II acromion. The patients were evaluated preoperatively and an average of 15 months postoperatively with the American Shoulder and Elbow Surgeons Score. The authors reported no significant difference between groups of both final ASES scores and improvement from baseline. While these results suggest there was no difference in ASES scores between groups, this study was not sufficiently powered to detect the minimally clinically important improvement.

Another randomized, prospective study81 compared 40 patients treated with an arthroscopic rotator cuff repair, anterior acromioplasty and coracoacromial ligament release with 40 patients who underwent rotator cuff repair alone. All patients had a repairable full thickness tear and either a Bigliani type II or III acromion. At two years postoperatively, the authors reported no significant differences in final Constant-Murley scores or DASH scores. The Constant-Murley scores are suggestive that acromioplasty has no effect on outcome. The work group considered the DASH result a true negative because this study was sufficiently powered to show the nonsignificant result was also not clinically significant. These results suggest that acromioplasty has little or no effect on postoperative clinical outcomes; therefore it is not required for the management of normal acromial bone (including type II and III morphology at the time of rotator cuff repair).

Acromial spurs are independent from normal acromial bone. Spurs have been identified as acquired ossifications of the coracoacromial ligament on the undersurface of the acromion. This ossification is considered in excess of normal acromial bone and may have a pathological role in the process of rotator cuff disease. The work group recognizes that acquired acromial spurs are a topic of interest to many surgeons; however they are beyond the scope of the current guideline."

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The acromion and rotator cuff tears and impingement - JSES

A recent article in the Journal of Shoulder and Elbow Surgery explored the reliability of the radiographic interpretation of the acromial shape as well as the associations of acromial morphology with the presence of  rotator cuff tears in asymptomatic patients. The authors found poor agreement among three observers on the acromial type (I, II or III). Neither the acromial type nor the acromial index were statistically associated with the presence of a rotator cuff tear. The presence of an acromial spur was strongly associated with the presence of a cuff tear, but the authors were careful to point out that this association demonstrated causation (which is the chicken and which is the egg) or that 'impingement' was the common mechanism for rotator cuff failure.

Readers may wish to review previous posts on this topic.

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