Rotator Cuff Treatment.

Last updated Wednesday, January 26, 2005

Figure 29

Figure 30

Figure 31

Failed acromioplasty

Failure to achieve relief of symptoms

Such results occur in every series of acromioplasty, even if the technique of the procedure seems appropriate. The incidence of these failures ranges from 3 to 11 per cent. (Neer, 1972, Post and Cohen, 1985, Raggio, Warren, 1985, Thorling, Bjerneld, 1985) In Post and Cohen's series, 11 per cent continued to have significant pain after surgery. (Post and Cohen, 1985, Post and Cohen, 1986) Fifty-six per cent of those with weakness before surgery still had weakness postoperatively; 29 per cent of those with preoperative limitations of motion still had limitation of motion after surgery. The rate of return to high-level athletics or challenging occupations is lower. Tibone and colleagues (Tibone, Jobe, 1985) found that of 35 athletes having impingement syndrome treated by anterior acromioplasty, 20 per cent still had moderate to severe pain, and 9 per cent had pain at rest and with activities of daily living. Only 43 per cent returned to their preinjury level of competitive athletics, and only 4 of 18 returned to competitive throwing. Hawkins and coworkers (Hawkins, Chris, 1987) have shown that it is difficult for patients injured on the job to return to their original occupations following acromioplasty.

Why is this? Failure to achieve complete relief of symptoms through acromioplasty may indicate:

1. pathology other than subacromial roughness,
2. failure to achieve subacromial smoothness,
3. failure of deltoid reattachment,
4. excessive acromial resection,
5. postoperative complications such as dense scarring between the cuff and the acromion, or
6. failure of rehabilitation.

Many of these problems can leave the patient more symptomatic than before the surgery.

Acromioclavicular joint problems were thought to be responsible for five failures in Post's series, a "frequent cause of failure of surgical treatment" in the series of Penny and Welsh, (Penny and Welsh, 1981) and the cause of the only unsatisfactory result in Neer's series. In their series of patients having persisting problems after acromioplasty, Hawkins and colleagues (Hawkins, Chris, 1987) reported that forty-five per cent of the patients had a diagnosis other than continuing impingement, including acromioclavicular joint problems, cervical spondylosis, reflex sympathetic dystrophy, rotator cuff tear, thoracic outlet syndrome, glenohumeral osteoarthritis, and glenohumeral instability. Thirty-three per cent were thought to have continuing subacromial abrasion. The striking finding in this series was the relative lack of improvement in patients on workmen's compensation after revision acromioplasty. Even in these authors' series of primary acromioplasties, twenty-two per cent of the workmen's compensation cases had an unsatisfactory result, compared with eight per cent failure rate with non--workmen's compensation cases. (Hawkins and Brock, 1979) Post and Cohen (Post and Cohen, 1986) also observed that worse results were obtained from surgery performed for work-related impingement syndrome. This inability to return to work may be due to partial-thickness cuff tears, residual tendon scarring, and residual weakness. Post and Cohen emphasized the need for recovery of muscle strength before the laborer is returned to work; otherwise, recurrence can be anticipated. The difficulty of returning workers to their jobs after acromioplasty is reminiscent of the problems described by Tibone and coworkers (Tibone, Jobe, 1985) in returning athletes to a competitive level of function.

Bosley (Bosley, 1991) reported that most failures were attributed to either the underlying pathology or to failure of deltoid reattachment. Bjorkenheim et al (Bjorkenheim, Paavolainen, 1990) reported a failure rate of over twenty-five per cent, attributing the failures to "associated bony as well as soft-tissue subacromial lesions". Oglvie-Harris et al ( Ogilvie-Harris, Wiley, 1990) evaluated 67 shoulders in 65 patients who had pain and dysfunction for more than two years after an initial acromioplasty for impingement syndrome without a rotator cuff tear. In almost half of the cases there were "diagnostic errors" and even in those where there was a correct diagnosis and no operative errors, the failure rate was almost twenty per cent.

Radical acromionectomy may worsen a patient's comfort and function. This procedure removes the origin of the deltoid muscle and facilitates scar formation between the deltoid muscle and the rotator cuff. Neer and Marberry have pointed out that a radical acromionectomy may seriously compromise shoulder function without achieving subacromial smoothness. (Neer and Marberry, 1981) In their series of thirty patients, all had marked shoulder weakness and almost all had persistent pain. In the twenty shoulders reoperated upon, all had a retracted and scarred middle deltoid that was adherent to the cuff and humerus. Fifteen of the patients had residual cuff tears. Attempts to reconstruct these severely damaged shoulders were disappointing. The effects of loss of the deltoid attachment and the permanent contracture could not be reversed. In addition, these authors observed a high incidence of wound problems and infections following the radical acromionectomy, which further complicated their attempts at revision.

To help understand some of the other causes of unsuccessful acromioplasty, Flugstad and coworkers (Flugstad, Matsen III, 1986) reviewed nineteen patients referred to the University of Washington Shoulder and Elbow Service because of persistent pain and stiffness after open acromioplasty performed elsewhere. The average age was 42; 16 were male. Eleven patients had a traumatic onset of their shoulder problem; eight of these were work related. The average time of postoperative immobilization was four weeks. At the time of presentation, the patients complained of pain and stiffness. Physical examination revealed an average of 126 degrees of forward flexion and 36 degrees of external rotation and internal rotation so that the thumb could touch T12. In thirteen of these patients revision surgery was performedafter an exercise program failed to improve their symptoms. The average interval between the initial surgery and revision surgery was fifteen months. At the revision surgery, ten patients had roughness of the undersurface of the acromion. Five patients had distinct spurs protruding from the lateral or medial acromion; eight patients had large amounts of subacromial scarring in which heavy bands of cicatrix connected the undersurface of the acromion to the rotator cuff. Three patients had acromioclavicular joint spurs, one had a large ununited acromial fragment, and another had an os acromial. Although no patient had a full-thickness cuff tear, the incidence of partial-thickness deep surface or midsubstance cuff tears is unknown. The revision surgical procedure included excision of scar tissue, revision of the acromioplasty to assure adequate resection of the anterior and inferior acromion, resection of acromioclavicular spurs, inspection of the rotator cuff, and careful deltoid repair. Immediately after surgery, gentle range-of-motion exercises were initiated to minimize restriction from postoperative scar. Follow-up at an average of ten months postoperatively revealed substantial although incomplete improvement in comfort, range of motion, and ability to work.

This report emphasizes the importance of accurate diagnosis and effective subacromial smoothing. However, the key lesson was the importance of rapid restoration of full joint motion before restricting adhesions have the opportunity to form: the average patient in this series had a one-month delay between surgery and the implementation of motion.

Authors' preferred method for the management of failed acromioplasty

Patients who have had previous acromioplasty with unsatisfactory results need to be carefully reevaluated to determine presence of stiffness, weakness, instability or persisting roughness. The social and vocational context of the shoulder problem must be reevaluated as well.

The Jackins non-operative program is instituted, even if the patient has already "had therapy"; since surgery has failed once already, there is plenty of time for conservatism and a period of observation.

Patients with positive tendon signs (see figure 29) may be considered for cuff imaging studies if these signs are refractory to rehabilitation. Vocational rehabilitation may be essential; if one procedure has not gotten the patient back to their job, the odds would seem not much better the second go-round.

Reoperation is considered in well-motivated patients with evidence of residual subacromial roughness or stiffness that is attributable to postoperative scarring in the humeroscapular motion interface (see figures 30 and 31). In contrast to primary acromioplasty, we are willing to reoperate on patients with refractory shoulder stiffness, because this stiffness may be due to dense scarring between the cuff and the acromion which cannot be managed nonoperatively. Our revision procedure is identical with the primary subacromial smoothing described earlier.

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