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Arthroscopic subacromial decompression

    Overview

    Learn the Arthroscopic subacromial decompression surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Arthroscopic subacromial decompression surgical procedure.
    Fractures of the humeral greater tuberosity are common. The vast majority are undisplaced avulsion type injuries from the greater tuberosity at the insertion of the rotator cuff tendons. Most often these occur as a result of a fall, usually with a direct blow to the shoulder. They can occur following simple falls from standing height or after higher energy injuries, often during sporting activity. When displacement of such a fracture occurs it is a radiological indication of a rotator cuff avulsion which should be treated surgically, with repair either using suture anchors or screws and suitable suture material. In the case of an undisplaced fracture, conservative treatment should be instigated with rest in a broad arm sling and weekly x-ray monitoring of the position of the fracture. Active forward elevation and abduction of the shoulder should be avoided for at least the first two weeks and then progressed as comfort allows, with graduated active assisted mobilisation commenced under the guidance of a physiotherapist.
    Whilst the majority of patients will get a good result with the conservative management, some restriction in both movement and activity with associated pain from the subacromial space can result. Such subacromial pain often manifests as pain within the deltoid distribution towards the lateral aspect of the upper arm. Anything that obstructs the subacromial space may result in pain and “catching” symptoms, classically described as subacromial impingement signs. This can be further managed with conservative measures such as anti-inflammatory medication, steroid and local anaesthetic injection to the subacromial space and continued physiotherapy, including mobilisation exercises, stretches and strengthening. Persistence of such symptoms however are an indication for intervention with arthroscopic surgery to decompress the space so-called subacromial decompression.
    Arthroscopic subacromial decompression is a common surgical procedure and has been well described over the last thirty years. As technology has advanced the techniques have been altered, adapted and improved, with the intention of optimising patient outcome. Most common indications for the operation are subacromial impingement syndrome with or without partial thickness rotator cuff tear and as a combined procedure with rotator cuff repair, excision of calcific deposits or excision of the acromioclavicular joint. In my practice all arthroscopic shoulder procedures start with an arthroscopic inspection of the glenohumeral joint itself. This then allows identification of any associated intra-articular pathologies, which can be easily addressed at the same time as the decompression. Within the subacromial space the decompression includes a thorough bursectomy, release and excision of the coracoacromial ligament and bony acromioplasty.


    Indications

    INDICATIONS
    The indication for arthroscopic subacromial decompression is a patient with a history, examination and investigation findings concurring with obstruction of the subacromial space, following a failure of conservative management.
    SYMPTOMS & EXAMINATION
    The patient will give a history of injury to their shoulder and should know of their diagnosis of a fracture of the greater tuberosity. They will have been through a period of conservative treatment, including physiotherapy. They will describe pain around the shoulder girdle, often described as a constant aching sensation, from the anterolateral aspect of the shoulder radiating to the region of the deltoid muscles’ insertion on the lateral upper arm. They may describe “catching” exacerbations of pain with certain movements, particularly with repetitive activities or movements above head height. They may struggle to lie on the injured side and will often report having been woken from sleep, sometimes several times per night, due to shoulder pain. They may be experiencing some clicking or flicking sensations within the shoulder. On examination, they are most likely to have symmetrical shoulder girdles, although any period of inactivity or avoidance of use may result in some relative muscle wasting. There may be some tenderness to palpation around the anterolateral aspect of the acromion and with the rotational movements of the humeral head under the coracoacromial arch. Audible or palpable crepitus may be reproduced. It is important to assess passive and active range of motion comparing with the opposite side. I always document range of external rotation, glenohumeral abduction, total active elevation and internal rotation. Rotator cuff strength should also be assessed for all rotator cuff muscles. Strength of resisted elevation in the plane of the scapula will test supraspinatus. Strength of external rotation by resisting turning out of the hand, with the elbow flexed and by the side, assesses infraspinatus and assessment of the power of internal rotation, using either DeBeer’s hug tests, the belly push test or Gerber’s lift off test, examines the subscapularis. There are also numerous tests for subacromial impingement. Personally I test by resisting external rotation of the abducted shoulder, which if it reproduces the patients’ pain can be regarded as a positive test. As always when examining the shoulder girdle, assessment of the neurological status of the upper limb should be tested and documented carefully.
    IMAGING
    In the case of a greater tuberosity fracture, serial plane x-rays should have been performed. I always image a shoulder with three view plain x-rays – anteroposterior (AP), lateral outlet and axillary views. The morphology of the acromion should be assessed from the lateral outlet image, looking at whether the acromion is flat, curved or hooked. In addition to the plain x-rays, further imaging could be used.
    Most commonly ultrasound scan or cross-sectional imaging with an MRI or CT scan is also used. These further imaging modalities will be to assess that the fracture has united but also to assess the integrity of the rotator cuff insertion. Ultrasound is very dependant on the user to interpret the images seen dynamically at the time of the investigation but MRI scan is also used to look at the quality of soft tissues and whether there is a partial or full thickness rotator cuff tear. This will be very useful in planning surgical management.
    ALTERNATIVE OPERATIVE TREATMENT
    The open equivalent of the arthroscopic procedure could be theoretically considered. Open subacromial decompression and debridement of subacromial space in reality has little place in contemporary shoulder surgery, given the advances in technology for arthroscopic surgery and the ease of being able to inspect both the glenohumeral joint and subacromial space with arthroscopy.
    NON-OPERATIVE MANAGEMENT
    This would consist of analgesia and anti-inflammatory oral medications, repeated injections of steroid and local anaesthetic to the subacromial space, in combination with physiotherapy, osteopathic or chiropractic manipulative techniques, exercises, stretches and strengthening
    CONTRAINDICATIONS
    These are as with any patient treated surgically. Their condition, their general medical health and co-morbidities must be taken into consideration. The patient must be able to comply with relatively straightforward physiotherapy in the postoperative period and ongoing rehabilitation instruction, to optimise their function. The general state of the skin around their shoulder girdle, including axilla should be taken into account and if at all possible, normal.

    Setup

    The procedure is performed in the beach chair position using an appropriate operating table attachment and under general anaesthetic (aiming to keep the systolic blood pressure at approximately 100mmHg) supplemented by suprascapular nerve block (performed by the anaesthetist under ultrasound guidance). An alternative, depending on the patient’s medical and pain relief requirements, is to use an interscalene brachial plexus nerve block. Flowtron intermittent calf compression is used as mechanical thromboembolic prophylaxis. No prophylactic antibiotics are required for such arthroscopy.
    I use the T-Max (marketed in the UK by Smith & Nephew) table attachment as shown. The patient is slid onto the table and both side supports are fixed into position. The wedge is then placed under the patient’s legs and the power assisted table attachment can then be elevated to a suitable beach chair position. The patient’s head is positioned safely on the table head piece, adjusting the position with the anaesthetist’s approval and secured using the foam face mask clipped into position as shown.
    The Trimano (Arthrex) arm positioned is attached to the edge of the operating table in a position that will reach the operated hand and arm. The Trimano is then covered with the sterile plastic cover, attaching the black fitment to its end. Starting with the hand, the whole upper limb to the base of the neck and across the axilla and chest wall is prepared with chlorhexidine and then covered with specifically designed beach chair shoulder arthroscopy drape. The blue foam arm-holder is clicked into place on the black Trimano fitment and then folded over and secured with the Velcro edges to wrap the forearm. The blue foam arm-holder is then wrapped in self-adhesive stretch tape, to hold the arm in position during surgery. The Trimano can be single-handedly manoeuvred to hold the shoulder in different positions during the operation with traction as required. A 30⁰ shoulder arthroscope is used and the arthroscopic pump instils saline at approximately 50mmHg.

    Operation – 1

    An AP plain x-ray of left shoulder following an injury involving a fall from standing height and landing heavily onto the point of the shoulder. The X-ray shows the undisplaced fracture (F) of the greater tuberosity.

    The lateral plain x-ray showing the fracture (F). Of note, this lateral outlet view shows relative obstruction of the subacromial space by the anatomical morphology of the acromion (A). The shape of this acromion is somewhere between being curved and hooked and predisposes the patient to subacromial space obstruction and contributes to their symptoms.

    An axillary plane view x-ray of the same shoulder, showing again the undisplaced fracture of the greater tuberosity (F).

    Further AP x-ray at approximately 8 weeks following injury confirming that the greater tuberosity fracture has healed.

    Due to persistent symptoms an MRI was arranged at approximately 3 months following injury and fracture. This single coronal image from the MRI scan confirms that the greater tuberosity has united and also that the supraspinatus tendon attached to that bone is intact.

    The patient is placed on the T-Max operating table attachment, the head is placed on the moveable head piece (H) and secured in place by the foam facemask (FM). The side supports (S) are secured on both sides of the patient to ensure that he is safe on the operating table. The foam wedge (W) is placed beneath the patient’s knees. The Trimano (T) is attached to the side of the operating table, approximated to the operated arm.

    As documented in the setup, under general anaesthetic the anaesthetist here supplements the pain relief with a suprascapular nerve block performed under ultrasound guidance.
    With the patient in the beach chair position and while the operating surgeons are scrubbing, the anaesthetist uses ultrasound (US) with the probe (P) on the posterior aspect of the patient’s shoulder. This guides the position of the needle for instillation of local anaesthetic around the suprascapular nerve in the suprascapular notch.

    Further view of the ultrasound guided suprascapular nerve block showing the ultrasound probe in the anaesthetist’s left hand and the needle (N) being positioned with the his right hand. Our experience is that for subacromial arthroscopic surgery, such nerve block reduces the need for intraoperative opiate based analgesia and gives excellent postoperative pain relief, facilitating day case surgery.

    While an assistant holds the patient’s operated arm at the proximal forearm and elbow, the surgical team can start skin preparation using clear chlorhexidine solution on the hand.

    The hand can then be held by a sterile swab, whilst pink-staining chlorhexidine solution can then be used to prepare the skin of the entire shoulder girdle and the rest of the upper limb.

    The sterile black Trimano attachment (A) is applied to the Trimano arm positioner and the sterile plastic cover (C) is pulled over the length of the arm holder down to the operating table attachment.

    Once the Trimano is covered with the sterile bag, a beach chair specific shoulder arthroscopy drape is applied over the patient’s operated arm. The drape is placed over the patient’s head and covers the torso and legs towards the anaesthetic machine and around the back of the patient, ensuring that the arthroscopic instruments can be kept sterile.

    Once the arthroscopy drape is in position, the blue foam arm-holder (AH) is then clipped into position onto the black Trimano attachment.

    The arm positioned in the blue foam arm-holder.

    Self-adhesive stretch bandage is then wrapped around the wrist and hand, to secure the arm in the arm-holder.

    The self-adhesive wrap is continued up the forearm.

    Final preparations include positioning of the arthroscopic instruments. I have the arthroscopy camera cable, light lead and water source positioned behind the patient, attached to the drapes with Velcro attachment. The radio-frequency ablation wand and shaver come across the patient’s lap, again attached to the drape with Velcro attachment. All is set up now to start surgery.

    Skin markings show the anatomical landmarks of the distal clavicle (C), the acromion (A) and the position of the two most commonly used arthroscopic port sites. The posterior port site (P) is in the posterior soft spot of the shoulder approximately 2 cm below and medial to the posterolateral corner of the acromion. The lateral portal site (L) is approximately halfway from posterior to anterior on the humeral head, in line with the front edge of the acromion process and approximately 3 cms from the lateral edge of the acromion.

    This shows injection of local anaesthetic with adrenaline (I use 20 mls of 0.5% bupivacaine with adrenaline). I start by instilling a small amount into the glenohumeral joint – staying perpendicular to the spine of the scapular I insert the needle to the soft spot, heading anteriorly to the position of the coracoid process. I continue injecting local anaesthetic along the tract of the posterior port whilst withdrawing the needle.

    This shows installation of local anaesthetic and adrenaline to the subacromial space from the lateral port site, to anaesthetise the area of the lateral port.

    The arthroscopic trocar is inserted to the small stab incision for the posterior portal and advanced into the glenohumeral joint, keeping the trocar perpendicular to the spine of the scapular and heading towards the coracoid process anteriorly. Experience allows easy passage between the humeral head and the glenoid.

    The first arthroscopic image viewed from the posterior portal, showing humeral head (HH) and glenoid (G). Adherent to the front of the glenoid is the glenoid labrum (GL). In the distance, anterior to the glenoid labrum, the rotator interval (RI) capsule can be seen more pink in colour than the labrum.

    I use a 30⁰ arthroscope where the camera lens faces away from the position of the light lead on the arthroscope. By rotating the light lead to the floor, enables inspection superiorly within the glenohumeral joint and this identifies the long-headed biceps (LHB) tendon inserting at the superior glenoid labrum. The pink area below the long head of biceps is the rotator interval capsule (RI).

    Now looking down and lateral to identify humeral head (HH), the upper edge of the tendon of subscapularis (SSc) and the rotator interval (RI).

    Looking further superiorly and laterally to the superior aspect of the articular surface of the humeral head (HH). Above and lateral to this is the rotator cuff insertion and here it can be seen that the supraspinatus insertion (SSp) is frayed in keeping with partial tearing at the site of the greater tuberosity fracture. In the distance the long head of biceps (LHB) can be seen.

    Operation – 2

    The decision is made to make an anterior portal to allow introduction of instruments to debride the frayed undersurface of supraspinatus. Here a large hypodermic white needle (N) is inserted just anterior to the acromioclavicular joint (ACJ). This can be viewed from the arthroscope to be entering the glenohumeral joint into the rotator interval tissue between the tendons of long head of biceps and subscapularis.

    The white needle is removed and the skin incised to create the anterior portal (A) at the same site.

    A small artery clip is placed into the incision of the anterior portal and the teeth can be opened to stretch open the capsule and this can be seen under direct vision from the arthroscope in the posterior portal.

    The Arthrocare multivac 90 radio frequency ablation wand (W) can be inserted into the anterior portal as shown.

    Arthroscopic image showing insertion of arthroscopic wand (W) into the glenohumeral joint beneath the long-head of biceps tendon (LHB).

    Here the arthroscope (A) can be seen in the posterior portal, with the wand (W) in the anterior portal. The arthroscope leads come behind the patient and the wand leads come over the front of the patient. This shows the position of the arthroscopic monitor (M) at the top of the stack, which includes the image capture (IC) on top of the light source (LS).

    The wand is used to ablate the frayed tissue on the undersurface of supraspinatus taking care not to touch the electrode on the articular surface of the humeral head.

    The frayed tissue is here being ablated using the wand over the top of the long head of biceps tendon.

    The wand can be exchanged for the arthroscopic shaver (S) which is placed into the anterior portal.

    Ensure suction tube is attached to end of the shaver handpiece. All arthroscopic equipment companies have variety of different shaver blades. Here I am using the Smith & Nephew Dyonics shaver handpiece with the orange and black coloured ‘bone cutter’ shaver attachment. This allows good clearance of soft tissues using the oscillating function, as well as resecting bone in fast forward mode. The surgeon’s thumb operates the suction switch on the shaver hand piece.

    Here the shaver blade can be seen within the glenohumeral joint on the arthroscopy monitor. This used to resect any residual frayed soft tissue sucking away the debris.

    Final arthroscopic image of glenohumeral joint showing intact rotator cuff insertion of supraspinatus (SSp). The partial articular tear of the tendon has been debrided back to a stable margin at the top of the humeral head (HH). Long head of biceps (LHB) can be seen in the distance.

    Once finished within the glenohumeral joint, attention is turned to the subacromial space. Remove the arthroscope from the shoulder. Replace the trocar into the sheath and re-insert into the posterior portal but rather than entering the glenohumeral joint, drop the hand to pass underneath the acromion in the direction of the anterolateral tip of the acromion, seen here being palpated by the surgeon’s left index finger. The trocar can be advanced until it is felt to breach the bursal tissue into the cavity of the subacromial space. Gentle rotation in the horizontal plane can then feel a flicking sensation of the end of the trocar against the coracoacromial ligament.

    Arthroscopic image of what is seen first within the subacromial space. Bursal tissue (B) is seen inferiorly and lining the roof of the subacromial space, adherent to the undersurface of the acromion is the coracoacromial ligament (CAL) which in this case shows slight scuffing.

    Using the ‘Out to In’ technique, the lateral portal is created. Insert a white hypodermic needle (N) from the lateral side of the shoulder into the subacromial space.

    The needle (N) is seen entering from lateral into the subacromial space with frayed bursal tissue surrounding.

    Once the position of the needle is established with a good angle of access to the coracoacromial ligament, then the needle is removed and the lateral skin incised using a No. 11 scalpel knife blade (K). This is advanced into the subacromial space, under direct vision with the arthroscope.

    The tip of the No 11 scalpel blade is watched into the subacromial space creating the latera port.

    Once the lateral portal is established, the arthroscopic wand can be introduced into the subacromial space.

    Arthroscopic image showing the wand (W) electrode ablating bursal tissue (B).

    The thin fibrous bursal plicae are broken down with the ablation wand’s electrode, to clear the space between the bursal surface of the rotator cuff and the coracoid acromion ligament on the undersurface of the acromion.

    Once the bursal tissue is cleared from the space using the wand (W), the coracoacromial ligament (CAL) becomes more obvious.

    The coracoacromial ligament runs from the superolateral edge of the coracoid up to and along the undersurface of the acromion. Using the ablation diathermy wand, ablate the ligament tissue to identify bone of the acromion in the roof of the subacromial space.

    This shows the position of the wand (W) in the lateral portal and the suction tubing attached to the end of that device. The arthroscope (A) is in the posterior portal for viewing the image seen on the monitor (M).

    Gentle rotation of the advancing ablation wand reflects the coracoacromial ligament from the bone of the acromion as a sheet of tissue.

    Operation – 3

    The lateral border of the acromion (A) should first be identified and then by reflecting the ligament from the bone, the anterior edge is identified. Once this is established, the coracoid acromion ligament (CAL) can be further peeled from the deltoid muscle and this plane should be developed with care. There will be blood vessels within this tissue and a prompt coagulation diathermy will be needed to stop any bleeding, as blood can quickly obstruct the visual field. The ablation wand (W) can be controlled either by finger switches on the handle of the instrument or by foot pedals. The blue switch/pedal activates the coagulation diathermy and the yellow switch/pedal activates the ablation function.

    Further dissection using the wand (W), will completely release the coracoid acromion ligament (CAL) from the acromion (A) superiorly and the coracoid inferomedially.

    A rongeur (R) instrument can be introduced from the lateral portal to grasp the coracoid acromion ligament (CAL) tissue. This can be retrieved from the lateral portal with gentle rotation movement, taking care not to lose the tissue within the deltoid muscle.

    In this picture, the rongeur (R) is being removed from the lateral portal. Also note a gauze swab (G) overlying the anterior portal which prevents a jet of water interfering with the surgical field.

    This shows the coracoid acromion ligament (CAL) tissue removed with the rongeur (R) from the lateral portal.

    The rongeur (R) is released and the coracoid acromion ligament tissue fragment (CAL) is discarded.

    This is quite a substantial piece of gritty ligament material measuring approximately 2 cm in length.

    The shaver is now taken and placed into the lateral portal whilst still viewing from posterior.

    Arthroscopic image from posterior showing the shaver (S) being used on continuous fast forward high speed to start the bony resection of the acromion (A). The resector is first placed up against the anterolateral corner of the acromion and with gentle rotation and advancing from lateral to medial, the bone is resected taking care not to damage the deltoid muscle (D).

    The diameter of this shaver blade is 5.5 mm and this is used as a guide as to how much depth of bone has been resected by advancing from lateral to medial across the front edge of the acromion.

    Resection of the anterior acromion is complete when there is a smooth resection line across the acromion, indicating 5.5 ml (the diameter of the shaver blade) of bone cleared.

    Having completed the initial resection of the anterior acromion, move the arthroscope from the posterior portal into the lateral portal. Here the light lead (L) can be seen pointing to the floor, indicating that the arthroscope will be looking superiorly to the acromion, given the 30⁰ angle of the lens.

    With the arthroscope in the lateral portal now, the shaver is introduced into the posterior portal. Here the surgeon’s left index finger on the hand holding the arthroscope is seen rotating the light lead. The light lead is now pointing superiorly, hence the view from the arthroscope would be down towards the rotator cuff inferiorly.

    Rotation of the light lead will move the image on the monitor so that the cut bony surface of the acromion (A) can be identified with the bursal surface of the rotator cuff (RCB) inferiorly. The shaver (S) blade is seen entering posteriorly from right to left.

    Here the shaver is used in fast forward mode with intermittent suction, activated by the thumb switch on the shaver handle, and this clears further soft tissue from the undersurface of the acromion.

    By moving the shaver blade up against the bone and starting medially on the acromion, the shaver blade can be swept across underneath the undersurface of the acromion to complete the resection using a posterior cutting block technique.

    This shows the completed bony acromioplasty with exposed cancellous bone on the acromion (A). The acromioclavicular joint (ACJ) is seen in the distance.

    Now remove the shaver from the posterior port and reinsert the ablation wand probe.

    The wand (W) is then used from the posterior portal to clear any residual soft tissue (S) from the undersurface of the acromion and in the posterior aspect of the subacromial space. The bursal surface of the rotator cuff (RCB) can also be inspected.

    This shows optimal position of the surgeon in line with the arthroscope in the lateral portal, using the wand in the posterior portal and the monitor in direct line of vision.

    Arthroscopic image showing the wand (W) resecting a bursal plica (BP) away from the bursal surface of the rotator cuff (RCB).

    This allows close inspection of the bursal surface of the rotator cuff (RCB) to ensure that there is no tear in the surface, either communicating with the glenohumeral joint as a full thickness tear requiring repair or a flap of partial thickness tear on the bursal surface which can be debrided.

    Once surgery in the subacromial space is complete the port sites are closed with single interrupted nylon stitches

    The stitches are cut short at less than 1 cm.

    Simple adhesive dressings with absorbent pads cover the three arthroscopic port sites. A further absorbent pad can be applied over the top with an adhesive dressing if required for pressure. The forearm is removed from the arm-holder and the arthroscopic drapes are removed. The anaesthetic is stopped and the patient is transferred from the operating table to their bed or a trolley. In such patient’s who have had destructive surgery with no reconstructive component, immobilisation in a sling is not required, unless pain necessitates such rest.

    Operation – 4
    Post Operative

    General Points
     Do not push through pain – remember pain inhibits rotator cuff control
     Do not sacrifice quality of movement for Range of Motion (ROM)
     Remember the pathophysiology of the rotator cuff may be degenerative and needs to be
    considered when progressing rehabilitation
    Immobilisation
     No formal period of immobilisation, sling maybe provided for comfort only
     Wean out of sling as soon as able and comfortable
    There are no specific time scales, progression occurs as symptoms and ROM allows- but
    NO SIGNIFICANT UPPER LIMB RESISTANCE WORK FOR 6 WEEKS
    The emphasis of rehabilitation should be based on:
     Scapula stability/ control and progressive strengthening
     Regaining range of movement of all affected joints
     Rotator cuff control, strength and stamina – remember all components of a functional cuff – Internal Rotation/External Rotation/Abduction
     Functional, general strengthening and core stability
     Postural re-education – work and leisure
     Assessing other associated areas as necessary, such as cervical and thoracic spine.
    Exercises should be pain free, but should challenge stamina
    Post Operative Day 1: Pendular exercises; Active assisted exercises– consider use of table slides or walk backs as well as supine elevation
    Driving, Light work, sedentary activity: 10 – 14 days but may return sooner if pain and function allow.
    Heavy work or sustained over head postures: minimum 6 weeks but dependent on symptoms – this is typically between 6-12 weeks
    Non contact sports: minimum 6 weeks as comfort and ROM allows
    Contact sports: minimum 6 weeks as comfort and ROM allows

    Recommended Reading

    Arthroscopic subacromial decompression: Analysis of one- to three-year results. H Ellman. Arthroscopy: J Arthroscopic & Related Surgery. Vol 3, Issue 3, 1987, pages 173-181.
    Original paper describing method of performing arthroscopic acromioplasty using basic arthroscopic techniques
    1-3 year results of initial 50 consecutive cases
    80% advanced subacromial impingement with no rotator cuff tear; 20% full thickness tears
    UCLA scores: 88% excellent/good; 12% fair/poor
    ”The procedure is technically demanding and to achieve a satisfactory result the criteria of open anterior acromioplasty must be met. ASAD is presented as alternative to open anterior acromioplasty in advanced stage 2 and selected cases of stage 3 subacromial impingement syndrome.”
    Arthroscopic subacromial decompression versus open acromioplasty. R Norlin. Arthroscopy: J Arthroscopic & Related Surgery. Vol 5, Issue 4, 1989, pages 321-323.
    Random prospective comparison conducted of 20 patients who underwent ASAD or Open Acromioplasty for subacromial impingement syndrome.
    Shows more rapid rehabilitation and better range of motion in the arthroscopic group
    Time of surgery shorter in arthroscopic compared to open surgery
    ”ASAD appears to be superior to open acromioplasty as treatment for subacromial impingement syndrome
    Arthroscopic treatment of symptomatic shoulders with minimally displaced greater tuberosity fracture. S Kim, K Ha. Arthroscopy: J Arthroscopic & Related Surgery. Vol 16, Issue 7, 2000, pages 695-700.
    Report of 23 patients with minimally displaced greater tuberosity fractures
    All had partial thickness tears on the articular surface of the rotator cuff tendon at the greater tuberosity fracture site
    Partial tears were debrided (or repaired if appropriate) in addition to arthroscopic subacromial decompression
    UCLA scores: 20 excellent/good; 3 fair/poor
    19 patients returned to previous functional level activities
    Patients engaged in overhead sports activity had lower level of return to activity
    In conclusion, partial articular rotator cuff tears should be considered in patients with chronic shoulder pain after minimally displaced fractures of the greater tuberosity. Arthroscopic debridement or repair is an appropriate procedure.
    Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three group, randomised surgical trial. D Beard, J Rees, J Cook, I Rombach, C Cooper, N Merritt, B Shirkey, J Donovan, S Gwilym, J Savulescu, J Moser, A Gray, M Jepson, I Tracey, A Judge, K Wartolowska, A Carr. The Lancet. Volume 391. Issue 10118. 27 Jan – 2 Feb 2018, pages 329-338.
    Multicentre, randomised, pragmatic, parallel group, placebo controlled, three group trial
    CSAW Trial – Can Shoulder Arthroscopy Work
    32 UK hospitals with 51 surgeons
    Patients with subacromial pain for at least 3 months with intact rotator cuffs who had completed a course of non-operative treatment with exercise therapy and at least one corticosteroid injection. Full thickness tears excluded.
    313 patients randomised: 106 ASAD; 103 Arthroscopy only; 104 no treatment – 23% 42% & 12% respectively did not receive their assigned treatment by 6 months
    Oxford Shoulder Score no difference between surgical groups at 6 months ; both surgical groups small benefit over no treatment but felt not to be clinically important
    ”The findings question the value of this operation for these indications and this should be communicated to patients during the shared treatment decision making process”

    Reference

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