Subacromial Smoothing.
Last updated Wednesday, January 26, 2005
Figure 2 - The deltoid muscle is split Figure 3 - Standard acromioplasty Figure 4 - Secure deltoid repair Surgical approach
The surgical approach to roughness in the humeroscapular motion interface must be guided by the location of the problem.Shoulder roughness after previous surgery A shoulder having roughness after previous surgery is generally
approached through the previous incision because this provides best
access to the postoperative scar. Prior to the incision, the passive
motion of the shoulder is verified under anesthesia. If tightness is
identified, the approach may need to be modified to allow appropriate surgical releases.Previously unoperated shoulders Previously unoperated shoulders with positive subacromial abrasion
signs are approached through an anterior-superior acromioplasty
approach. The incision is in the skin lines, crossing the anterior
corner of the acromion, and ending just lateral to the coracoid
process.
The deltoid muscle is split in line with its fibers through the
middle of the tendons, separating its anterior and middle thirds,
preserving the continuity of the tendinous fibers of origin with the
muscle. The subdeltoid bursa on the deep surface of this muscle is
entered. Thickened bursa is resected to help smooth the space and to
allow inspection of the subjacent rotator cuff. An evaluation of the
integrity of the cuff is made at this time.
If a cuff defect is present, its reparability is assessed. A
traditional acromioplasty with resection of a substantial amount of the
anterior inferior acromion and the coracoacromial ligament must be
avoided in the presence of a large irreparable rotator cuff defect.
This is because the coracoacromial arch provides needed secondary
stability when the primary stabilizing function of the cuff is rendered
ineffectual. Thus when substantial roughness of the nonarticular
humeroscapular motion interface exists in the presence of an
irreparable cuff defect, emphasis must be placed on smoothing the
contacting surfaces rather than "decompression."
Rough edges of the acromion, hypertrophic bursal tissue, prominent
tuberosities, previously placed sutures, scar, and irregular edges of
cuff tissue are removed to leave the smoothest possible nonarticular
humeroscapular motion interface.
We perform this smoothing sequentially, putting the arm through a
complete range of elevation and rotation, identifying bony contact
points and then smoothing them down with a bur or rongeur. This process
is continued until smoothness and lack of acromiohumeral contact can be
verified in all humeroscapular positions. Smoothness of the motion
between the anterior aspect of the subscapularis and the deep surface
of the muscles originating from the coracoid process must be verified
as well. Standard acromioplasty If the rotator cuff is intact or repairable with good quality
durable tissue, a standard acromioplasty is performed with resection of
the anterior undersurface of the acromion and coracoacromial ligament.
Again, the potential areas of contact are examined repeatedly in
different positions to assure that adequate smoothness of the
undersurface of the coracoacromial arch and the superficial surface of
the rotator cuff and humerus has been achieved. Major cuff defects are
repaired securely after appropriate releases so that the cuff is under
physiologic tension with the arm at the side.
Because the primary goal of the procedure is to regain smooth
motion, any repair must be sufficiently strong to allow immediate
postoperative passive ranging of the shoulder. Again, before closing,
the shoulder is put through a complete range of motion to verify
smoothness of the nonarticular humeroscapular motion interface, both in
the subacromial and coracoid areas. Deltoid repair The deltoid is repaired securely so that immediate postoperative motion
can be established. We hypothesize that immediate postoperative passive
motion induces the undifferentiated cells in the surgical site to
generate a smooth new motion interface, rather than irregular and
adherent opposing surfaces. For this reason we use immediate
postoperative continuous passive motion in the recovery room and
continue it until the patient can carry out his or her mobilization
program without assistance.
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