The Role of Subacromial Decompression in Patients Undergoing Arthroscopic Repair of Full-Thickness Tears of the Rotator Cuff: A Systematic Review and Meta-analysis
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Since originally described by Neer in 1972, acromioplasties have become 1 of the most commonly performed procedures in orthopaedic surgery. They are usually performed as part of a formal subacromial decompression (SAD), which involves an anteroinferior acromioplasty, coracoacromial ligament release, and subacromial bursectomy. In a population study by Vitale the volume of acromioplasties (isolated and combined with other procedures) in New York State increased by 254.4% over an 11-year period (1996 to 2006). Similarly, the mean number of arthroscopic acromioplasties increased by 142.3% among candidates eligible for part 2 of their orthopaedic surgery board certification examination over a 10-year period (1999 to 2008). The most common indication for an SAD remains subacromial impingement with or without a concomitant rotator cuff tear.
The rationale for performing an acromioplasty in the setting of rotator cuff repair (RCR) is historically anchored to the theory of extrinsic subacromial im- pingement, which has been popularized by Neer1 and Bigliani. This theory is grounded on the principle that acromial morphology is the initiating factor leading to dysfunction of the rotator cuff and eventual tearing. The influence of this theory on the practice of shoulder surgery has been profound because several authors have advocated that acromioplasty is an integral part of RCR. However, proponents of the intrinsic theory of rotator cuff failure purport that abnormalities of the rotator cuff occur when eccentric tensile overload occurs at a rate greater than the ability of the cuff to repair itself. According to the intrinsic theory, acromioplasty fails to address the primary problem of intratendinous degeneration or tendinosis. Potential benefits of acromioplasty include improved visualization for arthroscopic technique, as well as access to bleeding in the subacromial space, which may improve healing potential. Potential disadvantages of routine SAD include violation of the soft-tissue envelope during arthroscopy leading to intraoperative soft-tissue swelling, weakening of the deltoid origin by detachment of some of its anterior fibers, anterosuperior instability in the presence of a failed rotator cuff or irreparable tear, and the formation of adhesions between the raw exposed bone on the un- dersurface of the acromion and the underlying tendon, which in turn can limit smoothness, motion, comfort, and range of motion. There is also uncertainty as to whether acromioplasty can prevent the progression of rotator cuff failure.
On the basis of the framework proposed by the intrinsic theory of rotator cuff degeneration, several investigators have challenged whether SAD needs to be performed concomitantly with rotator cuff surgery. Budoff reported good and excellent results in 81% of cases at long-term follow-up (minimum of 5 years) in patients undergoing debridement alone for partial-thickness rotator cuff tears without simultaneous SAD. Matsen and colleagues also reported significant improvements in health-related quality of life and Simple Shoulder Test scores in 96 consecutive repairs of full-thickness tears of the rotator cuff without SAD. Both of the aforementioned studies did not have a control group, and hence direct comparisons could not be made.
At this time, there is ongoing debate as to whether acromioplasty results in improved outcomes in patients undergoing repair of full-thickness rotator cuff tears. To our knowledge, there is no systematic review published in the literature that has addressed this controversy. The objective of this systematic review was to identify and summarize the available Level I evidence to compare the efficacy of performing acromioplasty in patients undergoing repair of full-thickness tears of the rotator cuff. We hypothesized that there would be no difference in outcome among patients who did receive an acromioplasty and those who did not during arthroscopic repair of full-thickness rotator cuff tears.