Rotator Cuff

.. zed that the supraspinatus insertion to the greater tuberosity and the bicipital groove lie anterior to the coracoacromial arch with the shoulder in the neutral position and that with forward flexion of the shoulder these structures must pass beneath the arch, providing the opportunity for abrasion. He suggested a continuum from chronic bursitis and partial tears to complete tears of the supraspinatus tendon, which may extend to involve rupture of other parts of the cuff. He pointed out that the physical examination and plain radiographic findings were not reliable in differentiating chronic bursitis and partial tears from complete tears. Importantly, he emphasized that patients with partial tears seemed more prone to increased shoulder stiffness and that surgery in this situation was inadvisable until the stiffness had resolved. He described the use of a subacromial lidocaine injection to help localize the clinical problem and before acromioplasty as a useful guide of what the procedure would accomplish.

Neer described three different stages of the impingement syndrome. In Stage 1, reversible edema and hemorrhage are present in a patient under 25 years of age. In Stage 2, fibrosis and tendinitis affect the rotator cuff of a patient typically in the 25- to 40-year age group. Pain often recurs with activity. In Stage 3, bone spurs and tendon ruptures are present in the individual over 40 years of age.

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He emphasized the importance of non-operative management of cuff tendinitis. If surgery was performed, Neer pointed out the importance of preserving a secure acromial origin of the deltoid, a smooth resection of the undersurface of the anteroinferior acromion, the careful inspection for other sources of abrasion (such as the undersurface of the acromioclavicular joint), and careful postoperative rehabilitation.(Neer, 1972, Neer, 1983, Neer, Flatow, 1988) In 1972 Neer(Neer, 1972) described the indications for acromioplasty as (1) long-term disability from chronic bursitis and partial tears of the supraspinatus tendon or (2) complete tears of the supraspinatus. He pointed out that the physical and roentgenographic findings in these two categories were indistinguishable, including crepitus and tenderness over the supraspinatus with a painful arc of active elevation from 70 to 120 degrees and pain at the anterior edge of the acromion on forced elevation. Neer’s 1983 report(Neer, 1983) described candidates for acromioplasty as (1) patients with an arthrographically demonstrated cuff tear, (2) patients older than 40 years with negative arthrograms but persistent disability for one year despite adequate conservative treatment (including efforts to eliminate stiffness), provided that the pain can be temporarily eliminated by the subacromial injection of lidocaine, (3) certain patients under 40 with refractory Stage II impingement lesions, and (4) patients undergoing other procedures for conditions in which impingement is likely (such as total shoulder replacement in patients with rheumatoid arthritis or old fracture). The proposed goal of acromioplasty was to relieve mechanical wear at the critical area of the rotator cuff.

Surgery was not considered until any stiffness had resolved and until the disability had persisted for at least nine months. Even in patients who had had a previous lateral acromionectomy with continuing symptoms, Neer considered anterior acromioplasty, having found that many still had problems related to subacromial impingement. Neer also reported that the rare patient with an irreparable tear in the rotator cuff could be made more comfortable and could gain surprising function if impingement were relieved, as long as the deltoid origin was preserved.(Neer, 1983) Neer(Neer, 1983) recommended resection of small-unfused acromial growth centers and internal fixation of larger unfused segments in a manner that tilted the acromion upwards to avoid impingement. His indications for resections of the lateral clavicle included (1) arthritis of the acromioclavicular joint, (2) a need for greater exposure of the supraspinatus in a cuff repair, and (3) nonarthritic enlargement of the acromioclavicular joint resulting in impingement on the supraspinatus (in this situation only the undersurface of the joint was resected).(Neer, 1983) Additional approaches to subacromial abrasion have been proposed including coracoacromial ligament section,(Hawkins and Kennedy, 1980, Jackson, 1976, Kessel and Watson, 1977, Penny and Welsh, 1981) resection arthroplasty of the acromioclavicular joint,(Kessel and Watson, 1977) extensive acromionectomy,(Armstrong, 1949, Diamond, 1964, Hammond, 1962, Hammond, 1971, McLaughlin, 1944, Michelsson and Bakalim, 1977, Moseley, 1969, Smith-Petersen, Aufranc, 1943, Watson-Jones, 1960) and combined procedures such as acromioplasty, incision of the coracoacromial ligament, acromioclavicular resection arthroplasty, and excision of the intra-articular portion of the biceps tendon with tenodesis of the distal portion of the bicipital groove.(Ha’eri, Orth, 1982, Neviaser, Neviaser, 1982, Pujadas, 1970) Comparison of the results of these procedures is difficult owing to the heterogeneous patient groups and varying methods of evaluation. In 16 patients with chronic bursitis with fraying or partial tear of the supraspinatus, Neer(Neer, 1972) found that 15 attained satisfactory results (no significant pain, less than 20 degrees of limitation of overhead extension, and at least 75 per cent of normal strength).

Thorling and coworkers(Thorling, Bjerneld, 1985) found good to excellent results in 33 of 51 patients following acromioplasty (in 11 resection of the acromioclavicular joint was performed as well). Recently, arthroscopic acromioplasty has been introduced. The frequency with which this procedure is performed has increased dramatically as the strictness of Neer’s original indications for acromioplasty have been allowed to relax. Ellman(Ellman, 1987) presented the initial results on 50 consecutive cases of arthroscopic acromioplasty for Stage II impingement without cuff tear (40 cases) and for full-thickness cuff tear (20 cases). Eighty-eight per cent of the patients had excellent or good results, and the rest were unsatisfactory at a one- to three-year follow-up. He pointed out that the technique was technically demanding. Difficulties with arthroscopic acromioplasty range from inadequate subacromial smoothing on one hand to transection of the acromion or virtually total acromionectomy on the other.

In his early series of 100 arthroscopic acromioplasties, Gartsman(Gartsman, 1988) found that at an average of 18.5 months’ follow-up, 85 shoulders were improved and 15 were failures, of which 9 required subsequent open acromioplasty. The procedure took longer than open acromioplasty and did not speed the patient’s return to work or sport. Morrison(Morrison, 1988) reported a series of arthroscopic acromioplasties in which the quality of the result was closely correlated with the conversion of a curved or hooked acromion to a flat undersurface. Even though the indications for its performance are still being defined, arthroscopic acromioplasty is currently one of the commonest of all orthopedic procedures, being applied to shoulder pain, bursal hypertrophy, partial thickness cuff tears, calcific tendinitis, as well as reparable and irreparable rotator cuff tears.