Subacromial
Descompression
PAULO ROCKETT, M.D.
Porto Alegre
Brazil
Subacromial Impingement Syndrome
Extrinsic
compression of the
subacromial bursa
and rotator cuff by
the coracoacromial
arch structures
Neer, 1972.
Subacromial Impingement Syndrome
Impingement of the rotator cuff
beneath the coracoacromial arch
has been recognized as a cause of
shoulder pain.
Subacromial Impingement Syndrome
causes
Abnormal acromial slope (Type II or III)
Spurs arising at the acromioclavicular
joint
Subacromial Impingement Syndrome
causes
Spurs arising at the coracoacromial
ligament attachment
Displaced fracture of the greater
tuberosity
Distal clavicle
fracture
Subacromial Impingement Syndrome
causes
Axillary view
Unstable os acromiale
Subacromial Impingement Syndrome
open versus arthroscopic
Arthroscopic
subacromial
descompression
clearly provides
equal or better
than open
descompression
.
Arthroscopic Subacromial Descompression
advantages
Low morbidity (deltoid)
Earlier recovery
Outpatient – decreased
cost
Allows evaluation of
glenohumeral joint
Identification and
treatment of associated
glenohumeral pathology
Arthroscopic Subacromial Descompression
indications
Primary impingement (stage II)
Frayed rotator cuff tendons
Arthroscopic Subacromial Descompression
indications
Partial rotator cuff tears (comprising
less than 50% of the tendon)
Arthroscopic Subacromial Descompression
indications
Irreparable full-thickness tear of Rotator
Cuff
Arthroscopic Subacromial Descompression
exclusion critera
Adhesive capsulitis
Osteoarthritis
Instability
Arthroscopic Subacromial Descompression
patient selection
Age: > 35 years old
Chronic pain (anterolateral)
Failed conservative treatment (á 6
months)
Painful arc of active elevation ( > 90°)
Positive impingement sign/test (Neer)
Arthroscopic Subacromial Descompression
radiographic evaluation
AP/lateral in scapular
plane (IR,ER)
Axillary view
Supraspinatus outlet
view
AP of acromioclavicular
joint (15° cephalad)
Subacromial Impingement Syndrome
outlet view
Acromion
Morphology
Type I
relatively flat
curved, no more
Type II than humeral
head
hooked
Type III downward
Prognostic value
Rotator Cuff Tears
3%
24%
73%
Subacromial Impingement Syndrome
outlet view
Type I
Type II
Type III
relatively flat
curved
hooked
downward
3%
24%
Prognostic value - Rotator Cuff tears
73%
Subacromial Impingement Syndrome
outlet view
Planning surgical procedure:
Draw a line from the front tip to the back edge
Subacromial Impingement Syndrome
outlet view
Planning surgical procedure:
Draw another line along the posterior undersurface
Subacromial Impingement Syndrome
outlet view
Planning surgical procedure:
The distance between these lines is the amount of
bone that will be resected
Arthroscopic Subacromial Descompression
surgical technique
Anesthesia: interscalene regional block
or general
Arthroscopic Subacromial Descompression
surgical technique
Patient position:
lateral decubitus (rolled
back 30°)
Arm position: 30° of
abduction and 15° of
flexion
Skin traction: 5 to 7 Kg
Arthroscopic Subacromial Descompression
portals
Posterior:
1 cm medial and 1 cm inferior to
posterolateral acromial corner
Arthroscopic Subacromial Descompression
portals
Anterior:
midway lateral acromion and AC joint
2 cm distal anterior acromion
Arthroscopic Subacromial Descompression
portals
Lateral:
5 mm posterior to anterior acromial border
2-4 cm distal to lateral acromion
Arthroscopic Subacromial Descompression
surgery technique
Glenohumeral
inspection
(debridement):
Labrum
Biceps Tendon
Undersurface
of Rotator Cuff
Arthroscopic Subacromial Descompression
surgery technique
Subacromial bursectomy
Partial Coracoacromial Ligament release
Acromioplasty (convert to type I)
Be prepared to address associated
intraarticular pathology (41%)
Arthroscopic Subacromial Descompression
surgery technique – Os acromiale
Acromioplasty and excision if the unfused
segment is moveble
Arthroscopic Subacromial Descompression
method
153 shoulders
Type II - without Rotator Cuff tears
58
39%
Type III - with Rotator Cuff tears)
95
61%
Arthroscopic Subacromial Descompression
method
Type III (N=95)
Partial tears of the rotator cuff
Complete tears of the rotator cuff
29
30,6%
66
69,4%
Arthroscopic Subacromial Descompression
method
Type III (N=95)
Partial tears of the rotator cuff
29
30,6%
Bursal surface
9
9,4%
Articular side of tendon
13
13,6%
Both
7
7,3%
Arthroscopic Subacromial Descompression
method
Type III (N=95)
ASD and Debridement
60
63,2%
ASD and Suture Rotator Cuff
35
36,8%
Arthroscopic Subacromial Descompression
method
153 shoulders (out of 143 patients)
Follow-up data on 134 cases
1 to 10 years follow-up
Arthroscopic Subacromial Descompression
method
134 patients
Associated lesions (41%)
55
Glenoid labrum tears
9
Labrum tears + partial Biceps rupture
20
Labrum tears + Biceps tendinitis
3
Partial Biceps rupture
3
Biceps tendinitis
8
Calcifying tendinitis of the Supraspinatus
4
Glenohumeral arthritis
7
Glenohumeral instability
1
Arthroscopic Subacromial Descompression
results
134 patients
Evaluated: pain, range of motion (ROM), and
satisfaction level
Less pain than before
130
97%
Improved mobility
101
75%
Expressed satisfaction
129
96%
Arthroscopic Subacromial Descompression
results
8 patients (8,4%) had full-thickness
tears with retraction of the rotator cuff
53 coplaning
Arthroscopic Subacromial Descompression
results
O n e case of reoperation for distal
clavicle symptoms
Arthroscopic Subacromial Descompression
results
O n e case of reoperation for distal
clavicle symptoms