Acromioplasty should not be so hard to unlearn
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The value of an acromioplasty, or subacromial decompression, is controversial and currently not supported as routine or essential for value-based care to manage impingement syndrome or rotator cuff disease symptoms.
High-level investigations show the procedure is used more than needed for diagnosis of impingement syndrome and during rotator cuff repair surgery. The inability to unlearn a key concept, that the shape acromion’s and surgical alteration of its shape are important for treatment of impingement and rotator cuff problems, continues to support unnecessary use of acromioplasty to treat many shoulder patients.
Unlearning key concepts like these is difficult because we develop biases toward evidence that supports our well-entrenched beliefs and tend to discredit new data that challenge current understanding and practice.
In his 1972 thesis, Charles S. Neer II, MD, coined the term “impingement” for rotator cuff-related pain and disability, from bursitis to complete tendon tears. He believed the acromion’s anterior-lateral undersurface affected the development of these conditions. Following failed nonoperative treatment, Neer proposed that surgical resection of the anterolateral corner would offer relief of impingement symptoms, better visualization during rotator cuff surgery and prevent recurrence of impingement or cuff tears.
Evidence now supports that resection of the anterior-inferior acromion does not provide benefit for rotator cuff repair surgery and is not superior to nonoperative care for treatment of impingement syndrome with long-term follow-up.
Common shoulder pain due to rotator cuff pathology is manageable with rest, medication and avoiding activities that precipitate the pain. When discomfort persists, patients pursue medical advice. Except for young patients with post-traumatic shoulder pain, most patients have shoulder symptoms following a shoulder strain which is compounded by age-related cuff and muscle degeneration. Nonsurgical care is often effective for cuff-related shoulder pain. Unfortunately, the approach often used is based on a small subset of patients with shoulder pain, intolerable impairment and discomfort. High-quality investigations into treatment of rotator cuff problems generally show time, activity modification and therapeutic exercise are effective long-term vs. surgery.
Ultimately, even though available evidence regarding the value of our surgical interventions may be insufficient to develop dogmatic treatment recommendations, we still make such recommendations. The acromioplasty conundrum is proof.
Open or arthroscopic acromioplasty is performed for shoulder impairment due to rotator cuff bursitis, impingement, cuff degeneration or partial- and full-thickness cuff tears when the patient and surgeon believe nonoperative care has failed. The procedure is represented by CPT code 29826, which has been designated an add-on code. Acromioplasty cannot be reported as a standalone procedure because, more than 90% of the time, it has been listed with other codes, most commonly 29827 for rotator cuff repair.
Studies with level-1, -2 and -3 evidence show acromioplasty is unnecessary for the successful treatment of impingement or rotator cuff tears. Results indicate that altering the acromion’s shape does not have superior long-term results vs. activity modification, physical therapy (PT) and medication for the treatment of impingement syndrome and multiple studies fail to demonstrate improved outcomes with rotator cuff repair combined with an acromioplasty. Unfortunately, the decision to proceed with surgery is influenced by low expectations of PT, often after a brief effort.
Despite numerous studies that fail to support the value of acromioplasty, surgeon behavior based primarily on level-5 research will lead to more than 500,000 acromioplasties being performed in the U.S. in 2021. Many orthopedic surgeons cling to the theory that the shape of the acromion’s undersurface affects rotator cuff problems despite substantial evidence that discredits this concept and surgery to reshape the acromion improves outcomes.
In 2021, strong evidence indicates Neer’s theory has not stood the test of time. Acromioplasty is unsupported as routine or essential in value-based care to manage symptoms of impingement syndrome or rotator cuff disease.
- References:
- Abrams GD, et al. Am J Sports Med. 2014;doi:10.1177/0363546514529091.
- Chalmers PN, et al. J Shoulder Elbow Surg. 2020;doi:10.1016/j.jse.2019.12.035.
- Neer CS 2nd.Neer CS 2nd. J Bone Joint Surg Am. 1972;54:41-50.
- Yu E, et al. Arthroscopy. 2010;doi:10.1016/j.arthro.2010.02.029.
- For more information: Anthony A. Romeo, MD,
- is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
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