Rotator Cuff Repair: Acromioplasty, Evidence, and Patient Considerations

Is rotator Cuff Repair Better With or Without Acromioplasty?

The decision to perform acromioplasty alongside rotator cuff repair is complex and depends heavily on individual patient factors and the specific nature of the shoulder pathology; current evidence suggests that for many patients, routine acromioplasty may not offer significant additional benefit in terms of re-tear rates or functional outcomes, leading to a trend towards more selective application.

Introduction to Rotator Cuff Tears & Repair

The rotator cuff, a group of four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) and their tendons, plays a critical role in shoulder stability, mobility, and strength. Tears can result from acute trauma or chronic degeneration, leading to pain, weakness, and restricted movement. Surgical repair aims to reattach the torn tendon(s) to the humerus, restoring anatomical integrity and function. A key debate in shoulder surgery revolves around whether to perform an accompanying procedure known as acromioplasty.

Understanding Subacromial Impingement and Acromioplasty

Subacromial impingement syndrome occurs when the rotator cuff tendons (particularly the supraspinatus) and the subacromial bursa become compressed between the humeral head and the overlying acromion (a bony projection from the shoulder blade). This compression can lead to inflammation, pain, and, over time, contribute to rotator cuff degeneration and tearing. Factors contributing to impingement include:

• Acromial morphology: The shape of the acromion (flat, curved, or hooked) can predispose individuals to impingement. A hooked acromion (Type III Bigliani/Morrison classification) is often considered more impinging.
• Bone spurs (osteophytes): Abnormal bone growths can narrow the subacromial space.
• Thickened coracoacromial ligament: This ligament can also contribute to compression.

Acromioplasty, also known as subacromial decompression, is a surgical procedure designed to enlarge the subacromial space. It typically involves:

• Removing bone spurs from the underside of the acromion.
• Reshaping or flattening a hooked acromion.
• Potentially excising a portion of the thickened coracoacromial ligament. The traditional rationale behind acromioplasty in conjunction with rotator cuff repair was to remove any potential source of impingement that might hinder tendon healing or lead to a re-tear of the repaired cuff.

Rotator Cuff Repair with Concomitant Acromioplasty: The Traditional Approach

For many years, it was standard practice to perform subacromial decompression (acromioplasty) whenever a rotator cuff repair was undertaken. The belief was that if impingement was a causative factor in the initial tear, removing the impinging structures would:

• Reduce mechanical stress on the newly repaired tendon.
• Improve the healing environment.
• Minimize the risk of re-tear. This approach was based on the premise that chronic impingement directly leads to rotator cuff pathology and that addressing the impingement is crucial for long-term success.

Rotator Cuff Repair Without Acromioplasty: A Shifting Paradigm

In recent years, there has been a growing trend towards more selective use of acromioplasty during rotator cuff repair. This shift is driven by several factors:

• Re-evaluation of impingement as a primary cause: Some research suggests that impingement may often be a symptom or secondary factor rather than the sole or primary cause of rotator cuff tears, especially degenerative tears.
• Potential downsides of acromioplasty:
  • Deltoid muscle detachment: While rare with modern arthroscopic techniques, there's a theoretical risk of compromising the deltoid muscle attachment, which is crucial for shoulder function.
  • Increased pain: Some studies suggest that acromioplasty might lead to greater early post-operative pain due to increased bone and soft tissue manipulation.
  • Longer recovery: The additional surgical trauma could potentially prolong recovery time.
  • No proven benefit for re-tear rates: A growing body of evidence indicates that routine acromioplasty may not significantly improve rotator cuff healing rates or reduce re-tears.
• Focus on direct repair: The primary goal of surgery is robust repair of the torn tendon. If the subacromial space is deemed adequate or if impingement is not a significant factor, omitting acromioplasty simplifies the procedure.

The Scientific Evidence: What Do Studies Show?

The question of whether to perform acromioplasty has been extensively studied, with numerous randomized controlled trials and systematic reviews comparing outcomes.

• Functional Outcomes: Many studies have found no significant difference in patient-reported outcomes (pain, function, satisfaction), range of motion, or strength between patients who undergo rotator cuff repair with acromioplasty versus those who do not, particularly for isolated rotator cuff tears without significant bony impingement.
• Re-tear Rates: Crucially, meta-analyses and large-scale studies have generally failed to demonstrate a statistically significant reduction in re-tear rates when acromioplasty is added to rotator cuff repair. This suggests that the mechanical impingement may not be the primary driver of re-tear for many patients once the tendon is securely repaired.
• Cost-effectiveness: Omitting acromioplasty can potentially reduce operative time and surgical costs, without compromising patient outcomes in selected cases.

Key Considerations:

• Pre-existing bony spurs or severe acromial morphology: In cases where significant bony spurs or a severely hooked acromion are definitively identified as causing mechanical impingement on the intact or repaired tendon, acromioplasty may still be indicated. This is often determined by pre-operative imaging (X-rays, MRI) and intra-operative assessment.
• Concomitant pathology: If there are other significant issues in the subacromial space, such as severe bursitis or a thickened coracoacromial ligament contributing to pain, acromioplasty might be considered.
• Surgeon preference and experience: The decision often comes down to the individual surgeon's assessment, experience, and adherence to current evidence-based guidelines.

Patient-Specific Factors: The choice between the two approaches is increasingly individualized. Factors such as the patient's age, activity level, tear size and chronicity, and the presence of symptomatic impingement pre-operatively all play a role in the surgeon's decision-making process.

Rehabilitation Considerations

Regardless of whether acromioplasty is performed, the post-operative rehabilitation protocol remains critical for successful outcomes. This typically involves:

• Initial immobilization: To protect the healing repair.
• Gradual range of motion exercises: To restore mobility without stressing the repair.
• Progressive strengthening: To rebuild muscle strength and stability. While the overall principles are similar, some surgeons may allow for a slightly more accelerated initial rehabilitation phase in patients who did not undergo acromioplasty, due to less bone and soft tissue disruption. However, protection of the repaired tendon remains paramount.

Conclusion and Clinical Implications

The current body of evidence suggests that for many patients undergoing arthroscopic rotator cuff repair, routine acromioplasty does not provide a significant additional benefit in terms of functional outcomes or re-tear rates. This has led to a paradigm shift from routine to selective acromioplasty.

The decision to perform acromioplasty should be based on:

• Clear evidence of significant subacromial impingement: Such as large bony spurs or a severely hooked acromion that are deemed to be actively contributing to the pathology or impeding repair.
• Intra-operative findings: Direct visualization of the subacromial space during surgery.
• Patient-specific factors: Including their symptoms, anatomy, and functional goals.

For many patients with isolated rotator cuff tears, especially those without significant pre-existing bony impingement, a direct repair without acromioplasty may be equally effective, potentially leading to less early post-operative pain and a more streamlined recovery without compromising long-term success. Patients should have an open discussion with their orthopedic surgeon to understand the rationale behind the chosen surgical approach for their specific condition.

References/Further Reading

(Note: In a published article, specific references to peer-reviewed studies, systematic reviews, and clinical guidelines would be listed here to support the evidence-based claims.)