Date Published: December 19, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Lewis L. Shi, T. Bradley Edwards.
The incidence of acromioplasty has increased dramatically in recent decades, but its role in rotator cuff surgery has been debated. Neer popularized the extrinsic theory of rotator cuff pathology, where mechanical compression of the coracoacromial arch leads to tearing of the rotator cuff. Under this theory, acromioplasty is advocated to modify acromial morphology as an essential part of rotator cuff surgery. Proponents of the intrinsic theory suggest rotator cuff tendons undergo degeneration through aging and overuse, and that bursectomy alone without acromioplasty is sufficient.
There exist cadaveric studies, expert opinions, and numerous case series espousing both sides of the argument. Recently, however, numerous high-quality prospective randomized controlled trials have been published examining the role of acromioplasty. They have similar study design and randomization protocols, including groups of arthroscopic rotator cuff repair with bursectomy and acromioplasty versus isolated bursectomy. The results have been consistent across all studies, with no difference in the outcomes of the acromioplasty and isolated bursectomy groups. Current evidence does not support the routine use of acromioplasty in the treatment of rotator cuff disease.
Rotator cuff pathology is a spectrum of disease that includes subacromial bursitis, rotator cuff tendinosis, and partial-thickness and full-thickness rotator cuff tear. Neer coined the term impingement syndrome, which has been used to refer to the full range of rotator cuff abnormalities . It is the most commonly diagnosed disorder of the shoulder, accounting for half of all shoulder complaints .
The two models of impingement are the extrinsic or mechanical theory and intrinsic or degenerative theory. In the extrinsic model, espoused by Neer, mechanical compression of the coracoacromial arch leads to the rupture of the rotator cuff [7, 8]. Proponents of this theory advocate acromioplasty to modify acromial morphology as an integral part of rotator cuff surgery [1, 9, 10].
The incidence of acromioplasty has increased dramatically in recent decades. Vitale et al. searched two databases to examine trends in frequency of acromioplasty . In the first part of their study, they looked at the New York Statewide Planning and Research Cooperative System ambulatory surgery database from 1996 to 2006. It shows that in this span of 11 years, the incidence of acromioplasty increased from 30.0 to 101.9 per 100,000. The volume of acromioplasty procedures increased at a rate that was 3 times faster than the overall increase of orthopaedic ambulatory procedures. The authors then examined the American Board of Orthopaedic Surgery database from 1999 to 2008. This showed that from 1999 to 2008, the mean number of arthroscopic acromioplasties reported per candidate increased from 2.6 to 6.3, a 142.3% increase, compared to 13.0% increase in the mean number of all orthopaedic procedures. Yu and colleagues from the Mayo clinic also catalogued the rising incidence of anterior acromioplasty using medical records of residents in Olmsted County, Minnesota. The incidence increased from 3.3 per 100,000 from 1980 to 1985 to 19.0 per 100,000 from 2000 to 2005 .
Despite the dramatic increase in the number of acromioplasties being performed, there are numerous arguments for and against this procedure. Potential benefits of acromioplasty include improving coracoacromial arch anatomy to reduce extrinsic compression on the rotator cuff, improved arthroscopic visualization during rotator cuff repair, and inducing a healing response through bleeding bone in the subacromial space [1, 9, 10].
With the arguments for and against acromioplasty based on cadaveric studies and expert-level opinions, numerous investigators have used evidence-based methods to examine the role of acromioplasty in rotator cuff surgery.
There is increasing number of published reports examining the role of acromioplasty in the treatment of rotator cuff disease. On the basis of the current literature, patients have similar outcome independent of whether or not an acromioplasty is performed at short and intermediate followup, regardless of acromion morphology. The notable exception is that MacDonald reported a higher rate of reoperation at 24 months in the non acromioplasty group (P = 0.05) . The nonblinded nature of this study calls into question the validity of reoperation rate as a secondary outcome measure, a point the authors acknowledged.