REVISION ACROMlOPLASTY: AN ARTHROSCOPIC APPROACH

Stephen C. Weber, M.D.

I.   Revision of the failed acromioplasty has been around almost as long as the acromioplasty itself

A. Flugstad, Matsen et. al. Orthop Trans., 1986

B. Hawkins, et. al. Clin. Orthop., 1989

C. Oglivie-Harris, et. al. JBJS, 1990

D. Rockwood, et. al. JBJS, 1993

II.  All emphasized the multi-factorial nature of failure, with open exploration and revision of those patients with clinical and radiographic evidence of impingement. While improvement was noted, revision of these procedures open usually requires inpatient hospitalization and often damages an already injured deltoid. The success of revision work in this arena was so poor in Hawkin’s series for worker compensation patients that repeat surgery was not recommended.

III. Gartsman demonstrated that acromioplasties can be performed as well arthroscopically as open, with numerous prospective studies showing decreased morbidity with arthroscopic compared with open acromioplasty.

IV. This report reviews the first reported series of arthroscopically revised failed acromioplasties.

A. 41 patients

B. 30 male, 11 female

C. mean age=43.9

D. 32 work comp

E. 24 failed prior open 17 failed arthroscopic

F. These were severely disabled preoperatively

1. Mean UCLA score=16.53 (perfect=35)

2. pain score=2.34 (of 10)

G. Preoperative studies are shown in Table 1.

H. Careful physical exam and radiographs usually allowed these patients to be divided into three groups:

1. Patients who in retrospect did not appear to initially have impingement

(note that only 1/3 of these patients had a preoperative positive lidocaine impingement test (Table 2)

2. Patients with complications of their initial procedure (Table 3)

3. Patients with residual impingement-20 patients

V.      Results -overall good (graph 1). Mean UCLA score improved from 16.5-27.5. Treatment varied according to the diagnostic group:

A. Non impingement group (graph 2). Two patients were treated with shoulder arthroplasty and one with an open Bankart repair. Arthroscopic or arthroscopic assisted repairs were performed on the remainder.

B. Complications group (graph 3). Five patients with postoperative adhesive capsulitis were treated with arthroscopic lysis of adhesions as described by Oglivie-Harris. Post operative acromial fractures were treated with arthroscopic excision of the remaining anterior fragment.

C. Residual impingement group (graph 4).

1.      NOT EASY”

2.      exclude other diagnoses with glenohumeral exam

3.      slow careful work to recognize bony landmarks and avoid extensive bleeding

4.      cutting block essential to assess amount of resection to perform

D. Note that 17 of these patients failed with unrecognized intraarticular pathology eight would have been missed had they not been arthroscoped.

E. Work Comp. 59% of these patients returned to work. Mean results were not different from other patients, but two of three patients who remained in the poor group post surgery were work comp patients.

VI. Summary

A. Arthroscopic revision can be performed

B. Results appear to at least be as good as open revision

C. In the comp arena, results seem superior

D. Results do not approach the published for primary acromioplasty; the practice of accepting a marginal acromioplasty, especially arthroscopic, with the hope of later revision will not allow an excellent result.

 

Table 1. Pre operative Studies Study

CT Arthrogram --2

Arthrogram --20

MRI --16

Contrast MRI --1

Bone Scan --1