Arthroscopic vs. Open Acromioplasty
Abstract & Commentary
Synopsis: Both arthroscopic and open acromioplasty produced similarly satisfactory results, although the open technique appeared to have better improved pain and function on one outcome scale at 1 year.
Source: Spangehl MJ, et al. Journal of Shoulder and Elbow Surgeons. 2002;11:101-107.
Acromioplasty is a commonly performed surgical procedure to address impingement or rotator cuff syndrome. A portion of the anterior inferior aspect of the acromion is removed in order to increase the space for the rotator cuff. Both arthroscopic and open techniques have been advocated. The arthroscopic technique has the advantage of being less invasive, more cosmetic, minimizes trauma to the deltoid, and allows inspection of the glenohumeral joint. The open technique has the advantage of being technically easier and possibly having shorter operating time. It also allows direct visual inspection and palpation of the anterior-inferior acromion and the coracoacromial ligament. Previous reports have documented similar outcomes but quicker recovery times for the arthroscopic technique. No prospective, blinded, randomized studies have been performed to date comparing the arthroscopic and open technique.
Patients with a clinical diagnosis of impingement syndrome and without a rotator cuff tear were randomized to surgical treatment with open or arthroscopic acromioplasty. The patients were also stratified into groups by compensation claims, age older than 50, and ligamentous laxity. The techniques of both open and arthroscopic acromioplasty were standardized and performed by 3 different surgeons. For the open technique, the deltoid origin, acromial periosteum, and trapezius insertion were elevated as a flap for later optimal repair. The coracoacromial ligament was resected along with the antero-inferior portion of the acromion. Preliminary glenohumeral arthroscopy and bursectomy were not performed. For the arthroscopic technique, the glenohumeral joint was first inspected through a posterior portal. Arthroscopic subacromial decompression was then carried out through posterior and lateral portals using motorized instruments.
At a minimum 1-year follow-up, patients were evaluated clinically and radiographically and an examination was performed by an independent, blinded observer. The primary outcome measure was defined as improvement in pain and function. Secondary outcome measures included: 1) patient’s assessment of improvement or worsening, 2) overall patient satisfaction, 3) change in UCLA score, and 4) change in shoulder strength. There was no difference in one visual analog score, overall satisfaction, UCLA scores, anterior deltoid strength, or complications. However, a second visual analog score measuring improvement in pain and function showed better improvement in the open group. Workmen’s compensation patients showed improvement with surgery but worse scores pre- and post-operatively than non-workmen’s compensation patients. Settled claims fared better overall.
Spangehl and colleagues conclude that open and arthroscopic acromioplasties will both yield similar results in terms of overall satisfaction and some outcome measures, including deltoid strength. They note, however, that the open procedure may be superior for pain and function at 1 year.
Comment by William W. Colman, MD
This excellent paper provides additional valuable data to the open vs. arthroscopic debate for the treatment of impingement of the shoulder. Arthroscopists, however, may be puzzled by the findings presented in this paper. Spangehl et al did not offer a possible explanation as to why the open group may have obtained a higher visual analog score. If both procedures purport to decompress the subacromial space, then it is not clear why the arthroscopic technique would fare worse. Were some of the patients inadequately decompressed? Was the diagnosis incorrect for a subset of the arthroscopic group? Were the 3 surgeons unequally divided between the 2 groups thus introducing a potential bias? It should be emphasized that despite disparities on one visual scale measuring pain and function, the results were similar for all of the other measured parameters. This paper and others all support the contention that both arthroscopic and open procedures—if performed correctly—will reliably provide an effective decompression of the subacromial space with subsequent improvement in the clinical symptoms associated with impingement. It is this reviewer’s preference to perform the procedure arthroscopically because it allows evaluation of the glenohumeral joint, improved cosmesis, and quicker return to full activities.
Dr. Colman, Assistant Professor, Department of Orthopaedic Surgery, UCSF, San Francisco, CA, is Associate Editor of Sports Medicine Reports.
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