Arthroscopic cuff repair can be done safely without acromioplasty

The results showed no statistical difference between the acromioplasty and non-acromioplasty group.

Introduction

Subacromial decompression is part of most full thickness rotator cuff tears and has been for many years. For this month’s 4 Questions interview, I have asked Peter B. MacDonald, MD, FRCSC, to share his thoughts with us. His answers are based on data he and his colleagues have recently published. Their work challenges the concept that extensive decompression needs to be part of every rotator cuff repair.

Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: Why has subacromial decompression, such as acromioplasty, coracoacromial ligament resection and bursectomy, become such a routine part of full-thickness rotator cuff repairs?

Peter B. MacDonald, MD, FRCSC: The subacromial decompression including acromioplasty, coracoacromial ligament resection and bursectomy has been a relatively routine part of full-thickness rotator cuff repairs since the modern teaching of Charles S. Neer, MD. Neer believed firmly that rotator cuff tearing partially emanated from subacromial impingement, and spurring with excessive pressure on the rotator cuff in the shoulder elevated position. This pressure and wear was part of his theory for rotator cuff tearing. Association with the further work by Neer and Louis U. Bigliani, MD, led to a classification of acromial morphology including a profound hook of the acromion (type III), which had a high statistical correlation with full-thickness rotator cuff tearing. This is how rotator cuff repairs became associated with subacromial decompression.

Jackson: What was the hypothesis and methodology your recent study explored in this area?

Peter B. MacDonald

MacDonald: Our hypothesis was that one could safely perform a rotator cuff repair without acromioplasty or subacromial decompression and not compromise results. This was a prospective randomized, double-blind study between two orthopedic facilities between June 2003 and February 2011 with 102 patients enrolled and 86 patients randomized.

The primary outcome was a validated disease with specific quality of life measurements for rotator cuff disease, the WORC index. The results showed no statistical difference between the acromioplasty and non-acromioplasty group. The secondary outcome included the validated American Shoulder and Elbow Surgeons score, which also showed no differences between the groups.

Jackson: What were your basic results and conclusions after studying this question?

MacDonald: Of interest is that four patients (9%) in the group that had arthroscopic repair alone without acromioplasty required additional surgery by the 24-month time-point. The number of patients requiring additional surgery (acromioplasty) was greater in the group that had arthroscopic rotator cuff repair than in the group that had arthroscopic cuff repair and acromioplasty.

The results of this study and other studies suggest that, in most cases, arthroscopic cuff repair can be done safely without acromioplasty. However, there are reasons and situations where acromioplasty can be considered. Particularly in the setting of technical difficulties associated with a tight subacromial space, acromioplasty could be considered. This was not a factor that we studied, but was one factor noted in the no acromioplasty group, i.e., increasing technical difficulty. As well, there is a suggestion that in the no acromioplasty group, the occasional patient may have to return to the operating room in the first 2 years for decompression.

Jackson: Based upon your studies, what are your recommendations and suggested considerations for the orthopedic surgeon doing this surgery in clinical practice?

MacDonald: Surgeons should do whatever operation that they are comfortable with performing. If it is technically easier to perform a rotator cuff repair with acromioplasty, then surgeons should not hesitate to do it. If surgeons prefer not to do an acromioplasty with cuff repair, then the results will be satisfactory in most cases.

References:

• MacDonald P, McRae S, Leiter J, Mascarenhas R, et al. Arthroscopic rotator cuff repair with and without acromioplasty in the treatment of full-thickness rotator cuff tears: A multicenter, randomized controlled trial. J Bone Joint Surg Am. 2011; 93:1953-1960. doi:10.2106/JBJS.K.00488.

For more information:

• Peter B. MacDonald, MD, FRCSC, is a professor and head, Section of Orthopaedics, University of Manitoba. He can be reached at Pan Am Clinic, 75 Poseidon Bay, Winnipeg, Manitoba, Canada R3M 3E4; 204-925-7480; fax: 204-453-9032; email: pmacdonald@panamclinic.com.
• Disclosure: MacDonald has no relevant financial disclosures.