Comparing Surgical Treatments for Shoulder ImpingementEver since arthroscopic surgery became a possibility for shoulder surgery, surgeons have been debating and comparing the open incision technique against arthroscopy. Which one is better? Does it even matter in the end? The results of this meta-analysis may be able to answer the question once and for all for at least one procedure: acromioplasty.
Acromioplasty is the removal of the end of the acromion, the round end of a curved piece of bone that comes from the back of the scapula (shoulder blade) over the top of the shoulder. Some of the shoulder muscles of the rotator cuff pass under the acromion as they travel from the scapula to the humerus (upper arm bone). And for various reasons, the rotator cuff can get pinched there causing a painful problem called subacromial impingement syndrome. Subacromial just means under the acromion.
So you can see how removing the end of the acromion can take care of the problem. That brings us back to the original question: what's the best way to surgically remove the end of the acromion so it can no longer pinch the rotator cuff as it passes under the bone?
A meta-analysis has the power to end debates because it provides enough subjects to reach some final conclusions. After searching all the medical literature published from 2000 to 2007 plus all the presentations made on the topic at four major orthopedic meetings held during that time, the authors were able to come to shed some light by comparing results between the two procedures. They found nine studies that directly compared arthroscopic versus open acromioplasty surgeries.
It turns out that by the end of 12 months (one full year), patients had equal results in terms of complications after surgery and final outcomes such as range-of-motion, pain, and function. And patients reported equal levels of satisfaction with either procedure. It's what happens during those 12 months that's of significance. For example, patients undergoing the arthroscopic procedure were able to leave the hospital faster and go back to work sooner. On average, patients having the arthroscopic procedure were back at work two weeks before patients in the open acromioplasty group. And the open acromioplasty took longer, so combined with lost wages from a delay in return-to-work, there was more expense for operative time with the open technique.
Some surgeons think arthroscopic acromioplasty is a better way to go for several reasons. First, they are able to avoid cutting through the deltoid muscle. Deltoid sparing techniques make it possible for the patient to start moving the arm right away after surgery. They can get into rehab without delay -- and for competitive athletes, that is a very important feature. For those who care, the incisions for arthroscopic surgery are much smaller and far less noticeable than the scar that results from the open incision.
In summary, small studies comparing arthroscopic to open incision acromioplasty have not been able to consistently show how these two techniques compare. Results have been contradictory from one study to the next. That's why pooling the data from high quality studies in a meta-analysis is so helpful. With enough patients undergoing the same two procedures, analyses can be conducted that reach statistical significance. The authors conclude that although arthroscopic acromioplasty isn't superior to open incision surgery in every way, it does have some important socioeconomic advantages to consider.
A. David Davis, MD, et al. Arthroscopic Versus Open Acromioplasty. In The American Journal of Sports Medicine. March 2010. Vol. 38. No. 3. Pp. 613-618.
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