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il dottor Marco Spoliti Ortopedico illustra acromionplastica e decompressione sub acromiale

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Marco Spoliti Ortopedico illustra acromionplastica e decompressione sub acromiale in una conferenza sull' artroscopia ortopedica di spalla e ginocchio

Marco Spoliti Ortopedico illustra acromionplastica e decompressione sub acromiale in una conferenza sull' artroscopia ortopedica di spalla e ginocchio

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  • 1. DECOMPRESSIONE SUB-ACROMIALE M. SPOLITI U.O.C. DI CHIRURGIA ORTOPEDICA Az.Osp. SAN.CAMILLO-FORLANINI ROMA Primario: Prof. S. Rossetti wwwmarcospoliticom
  • 2. DECOMPRESSIONE SUB-ACROMIALE 1: Mauro CS, Jordan SS, Irrgang JJ, Harner CD. Practice patterns for subacromial decompression and rotator cuff repair: an analysis of the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am. 2012 Aug 15;94(16):1492-9. 2: Eyer-Silva Wde A, Netto Hde B, Pinto JF, Ferry FR, Neves-Motta R. Severe shoulder tendinopathy associated with levofloxacin. Braz J Infect Dis. 2012 Jul-Aug;16(4):393-5. PubMed PMID: 22846132 3: Magaji SA, Singh HP, Pandey RK. Arthroscopic subacromial decompression is effective in selected patients with shoulder impingement syndrome. J Bone Joint Surg Br. 2012 Aug;94(8):1086-9 4: Shishido H, Kikuchi S, Otoshi K, Konno S. Postoperative outcomes of arthroscopic subacromial decompression for rotator cuff tear with shoulder stiffness. Fukushima J Med Sci. 2012;58(1):33-9 5: Pillai A, Eranki V, Malal J, Nimon G. Outcomes of open subacromial decompression after failed arthroscopic acromioplasty. ISRN Surg. 2012;2012:806843. Epub 2012 May 9. 6: Misirlioglu M, Aydin A, Yildiz V, Dostbil A, Kilic M, Aydin P. Prevalence of the association of subacromial impingement with subcoracoid impingement and their clinical effects. J Int Med Res. 2012;40(2):810-5 7: Murphy CA, McDermott WJ, Petersen RK, Johnson SE, Baxter SA. Electromyographic analysis of the rotator cuff in postoperative shoulder patients during passive rehabilitation exercises. J Shoulder Elbow Surg. 2012 May 3 8: Cuff DJ, Pupello DR. Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol. J Shoulder Elbow Surg. 2012 Nov;21(11):1450-5 9: Gumina S, Albino P, Carbone S, Arceri V, Passaretti D, Candela V, Vestri A, Postacchini F. The relationship between acromion thickness and body habitus: practical implications in subacromial decompression procedures. Musculoskelet Surg. 2012 May;96 Suppl 1:S41-5. Epub 2012 . 10: Holmgren T, Björnsson Hallgren H, Öberg B, Adolfsson L, Johansson K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ. 2012 Feb 20;344:e787 11: Luyckx L, Luyckx T, Donceel P, Debeer P. Return to work after arthroscopic subacromial decompression. Acta Orthop Belg. 2011 Dec;77(6):737-42 12: Aydin A, Yildiz V, Kalali F, Yildirim OS, Topal M, Dostbil A. The role of acromion morphology in chronic subacromial impingement syndrome. Acta Orthop Belg. 2011 Dec;77(6):733-6. 13: Chahal J, Mall N, MacDonald PB, Van Thiel G, Cole BJ, Romeo AA, Verma NN. The role of subacromial decompression in patients undergoing arthroscopic repair of full-thickness tears of the rotator cuff: a systematic review and meta-analysis. Arthroscopy. 2012 May;28(5):720-7. 14: Barker SL, Johnstone AJ, Kumar K. In vivo temperature measurement in the subacromial bursa during arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2012 Jun;21(6):804-7 15: Balke M, Bielefeld R, Schmidt C, Dedy N, Liem D. Calcifying tendinitis of the shoulder: midterm results after arthroscopic treatment. Am J Sports Med. 2012 Mar;40(3):657-6 16: Donigan JA, Wolf BR. Arthroscopic subacromial decompression: acromioplasty versus bursectomy alone--does it really matter? A systematic review. Iowa Orthop J. 2011;31:121-6. 17: Franceschi F, Papalia R, Del Buono A, Maffulli N, Denaro V. Repair of partial tears of the rotator cuff. Sports Med Arthrosc. 2011 Dec;19(4):401-8 18: Gebremariam L, Hay EM, Koes BW, Huisstede BM. Effectiveness of surgical and postsurgical interventions for the subacromial impingement wwwmarcospoliticom syndrome: a systematic review. Arch Phys Med Rehabil. 2011 Nov;92(11):1900-13
  • 3. DECOMPRESSIONE SUB-ACROMIALE SINDROME DA CONFLITTO SUB-ACROMIALE “Sub-acromial Impingement Syndrome”- THE CHRONIC IMPINGEMENT SYNDROME THEORY DESCRIBED BY NEER IS THE BEST-KNOWN EXTRINSIC PATHOLOGICAL FACTOR IN RCTS. DOLORE E DISFUNZIONE DELLA SPALLA wwwmarcospoliticom
  • 4. i 23 22 25 50 53 ni 54 In io 60 te rn In t 41 az i 32 on a na l er na z io © CI C Ed izi lated RC tendon changes are more common in dianificant difference in the mi 29. Diabetic patients show a restricted shoulder Yergason test are useful to assess the long head bi- compared wit betics of the tear range of motion, higher incidence in retears the there of ceps9,11. Murrel and Walton compared after a resultswas increased vasc surgical repair, and higher rate of complications and from the tear42. Moseley a 12. Patients affected 23 commonly used shoulder tests lary distributions in cuff s infections are reported both after open and arthro30,31 . An association between scopic repair of RCT Review for supra- Via1 Alessio Giai by shoulder pain, and who tested positivearticle that no hypovascular area 32 . ConMauro De vessel obesity and RCTs has also been proposed that both Cupis1 diameter Marco Spoliti2 Clinical genital subacromial stenosis of a rare abnormality of and biological aspects is rotator cuff tears mately reduced by a third a Francesco Oliva1 Clinical and biological aspects of rotator cuff tears the subacromial arch and may predispose to impingecompared with 30 mm, bu Muscles, ment 33. Ligaments and Tendons Journal 2013; 3 (2): 70-79 exist 44. Indeed cular areas of Orthopaedic and Tra 1 Department Table 1. Extrinsic and intrinsic theories about etiopathogenesis of rotator cuff tears (RCTs). chemicalofand intraoperativ versity Rome „„Tor Vergata”, Sch Currently RCTs are considered to be multifactorial in Rome, Italy etiology, and the References contributions of these facrelative by first sis 2 reported of Orthopaedics and Department relative hyperp Theory 1 2. Two prospective studies, one Year Alessio Giai Viators remain to be determined. 5 to 30% ing from Soslowsky, in his study perSan zone, 45 and laser critical Camillo-Forlanini Hospital, Rom Mauro De Cupis1 formed with Magnetic Resonance Imaging (MRI) and showed hyperaemic resp Marco Spoliti2 on animal model, observed that the role of extrinsic the the other factors Extrinsic with ultrasonography, investigated Francesco Oliva1 prevalence of RCTs in individuals without pain and Corresponding data compression or overuse with apparently normal function. In the first study, tear46. These author: sugges factors without an additional Francesco Oliva Chronic impingement syndrome Neer 1972 Sher al. reported that 28% of patients older factor may be insufficient toetcause tendinopathy and than tear is not ofhypovascular, Department Trauma and Orthopae 1 Department of Orthopaedic and Traumatology, Uni3 . In the second 60 years had a full-thickness tear University of Rome “Tor Vergata” Codman Milgrom a type ultrasonographic prevathat an extrinsic compression, like reported anIII acromion, 1931, that the avascularity of the versity of Rome „„Tor Vergata”, School of Medicine, study Overuse School of Medicine McMaster of 65% of RCTs in patients older than 704. In 1993 Rome, Italy lence did not cause injury of the RC tendonsa until on cadaveric and tifact of techniques used d overuse 2 Department of Orthopaedics and Traumatology, Viale Oxford, 81 2006 Reilly published review 42. San Camillo-Forlanini Hospital, Rome, Italy Multifactorial Soslowsky activity was introduced 34imaging prevalence of RCTs5. The overall prevalence ies00133 Rome, Italy . More recently the prepon- 2004 was 23% in 4629 cadaveric shoulders. The prevae-mail: olivafrancesco@hot mail.com derance of evidence strongly RCTs increases that extrinsic the More than seventy years a lence of suggests linearly with age from Intrinsic factors Corresponding author: acromial compression is thirdaccordingprimary. cause of 55% in the generative theory for RCT notdecade, rising from 33% in the 40s to RC the to Milgrom4 Francesco Oliva 50s Summary Hypoperfusion theory Uhthoff Department of Trauma and Orthopaedic Surgery and cadaveric studies have found 1990 portance of degenerative pathology. Clinical University of Rome “Tor Vergata” Rotator cuff tears are common and that the School of Medicine theory majority of pathologic changes occur on the 1999 pathogenesis of tendon te Physical examination Degenerative Sano source of shoulder pain and dis Viale Oxford, 81 articular side of the supraspinatus and infraspinatus currently inconfirmed. of rot variation the prevalence His 00133 Rome, Italy The clinical diagnosis is not always easy. Painful conDegeneration-microtrauma Yadav 35 . This 2009 stumps of reported. The etiology has been torn RCTs and e-mail: olivafrancesco@hot mail.com tendon insertions, awayditions of the long acromion acromioclavicular from the head biceps6 or tear remains multifactorial and at joint may result in high false 36 positive rate7. The clinifinding was confirmed by presentation of et al. (RC) pathology is2002 ning and and extrinsic theoriesof c Apoptotic theory Yuan Buddoff rotator cuff . He also excal intrinsic disorientation trie Summary etiopathogenesis of rotator cuff te supposed that once RC tremely variable. A recent review concluded that generation, hyaline degene damage and weakness ocRCTs are frequently asymptomatic7. Such variation in of the etiopathogenesis of rotator Extra cellular matrix modifications Riley 2002 curs, the tendons are sia, calcification, our therapies Rotator cuff tears are common and are a frequentunable to effectively oppose the anclinical features is a question that remains to be portant to improve vascular source of shoulder pain and disability. A wide swered. Physical examination should include inspecniques and promote tendon repair variation in the prevalence of rotator cuff tears tion, palpation, the evaluation of active and passive gies have been proposed to enhan has been reported. The etiology of rotator cuff range of motion, the execution of strength and ing and recently research has Ten Muscles, Ligaments and foc tear remains multifactorial and attempts to unify provocative tests. While strengthstructural failure after RC repair is a spinatus weakness, weakness in external rotation, Rerupture or may be normal in 72 wwwmarcospoliticom
  • 5. DECOMPRESSIONE SUB-ACROMIALE SINDROME DA CONFLITTO SUB-ACROMIALE CONFLITTO TRA CUFFIA E ARCO CORACO ACROMIALE wwwmarcospoliticom
  • 6. CONFLITTO SUB-ACROMIALE 120° 60° Arco critico (contatto tra acromion - sovraspinoso e trochite) Aumento di contatto con 20° di rotazione interna Burns Wc II & Whipple TL Clin Orthop 1993 Anatomic relationships in the shoulder impingement syndrome. Flatow et al Am J Sport Med 1994 Excursion of the rotator cuff under the acromion: patterns of subacromial pattern. wwwmarcospoliticom
  • 7. DECOMPRESSIONE SUB-ACROMIALE SINDROME DA CONFLITTO SUB-ACROMIALE NEER 1983 - 3 STADI he said that the impingement of the rc against the undersurface of the acromion and cora- coacromial (ca) ligament was the primary factor in causing tendon tears. I. II. III. ALTERAZIONI REVERSIBILI: edema emorragia della cuffia dei rotatori ALTERAZIONI IRREVERSIBILI: fibrosi – fibrillazione - degenerazione LESIONI DELLA CUFFIA DEI ROTATORI Neer CS Clin Orthop 1983 Impingement Lesions. wwwmarcospoliticom
  • 8. DECOMPRESSIONE SUB-ACROMIALE ANATOMIA ARTROSCOPICA SPAZIO SUB-ACROMIALE Matthews & Fadale Arthroscopy 1989 TETTO 1. Clavicola laterale 2. Art. A-C 3. Acromion 4. Leg. Coaraco-Acromiale 3 4 PAVIMENTO A A. Sovraspinoso B. Porz. Sup.Sottospinoso C. Porz. Sup.Sottoscapolare B C 20% ANTERIORE • CORACOIDE LATERALE - POSTERIORE • DELTOIDE wwwmarcospoliticom
  • 9. DECOMPRESSIONE SUB-ACROMIALE ANATOMIA ARTROSCOPICA SPAZIO SUB-ACROMIALE Matthews & Fadale Arthroscopy 1989 wwwmarcospoliticom
  • 10. ALTERAZIONI SPAZIO SUB-ACROMIALE CONFLITTO SUB-ACROMIALE Clin Biomech 2003 Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Michenera L.A. et al Evidence exists to support the presence of the anatomical factors of inflammation of the tendons and bursa, degeneration of the tendons, weak or dysfunctional rotator cuff musculature, weak or dysfunctional scapular musculature, posterior glenohumeral capsule tightness, postural dysfunctions of the spinal column and scapula and bony or soft tissue abnormalities of the borders of the subacromial outlet. These entities may lead to or cause dysfunctional glenohumeral and scapulothoracic movement patterns. These various mechanisms, singularly or in combination may cause subacromial impingement syndrome. wwwmarcospoliticom
  • 11. ALTERAZIONI SPAZIO SUB-ACROMIALE STRUTTURALI FUNZIONALI Forma dell’acromion Discinesia scapolo-toracica Spessore dell’acromion Capsulari Os Acromiale Posturali Osteofitosi del Leg. C-a Degenerazione Intrinseca Cuffia wwwmarcospoliticom
  • 12. ALTERAZIONI SPAZIO SUB-ACROMIALE STRUTTURALI Forma dell’Acromion Neer CS. J Bone Joint Surg [AM] 1972 Anterior acromioplasty for chronic impingement syndrome in the shoulder: a preliminary report. Bigliani LU, et al. Orthop Trans1986 The morphology of the acromion and its relationshipto rotator cuff tears . I Studio su 140 cadaveri - 3 tipi di Acromion I. II. III. Piatto Curvo A Uncino 17% 43% 40% II 80% lesioni cuffia associate con tipo 3 Morrison DS - Bigliani LU, et al. Orthop Trans 1987 The clinical significance of variations in acromion morphology III wwwmarcospoliticom
  • 13. ALTERAZIONI SPAZIO SUB-ACROMIALE STRUTTURALI Spessore dell’Acromion Snyder SJ – Whu MC Oper Tech Orthop 1991 Arthroscopic management of the rotator cuff and superior labrumanterior posterior lesion. A. B. C. <8 mm 8-12mm >12mm A B C Posizione Orizzontale Acromion Edelson Jjc & Taiz C jbjs 1992 Anatomy of the coracoacromial arc: relationship to degeneration of the acromion Maggiore associazione tra lesioni di cuffia e posizione piu’orizzontale dell’acromion e lunghezza wwwmarcospoliticom
  • 14. ALTERAZIONI SPAZIO SUB-ACROMIALE STRUTTURALI Os Acromiale Mancata fusione nucleo ossificazione dell’epifisi anteriore dell’Acromion Presente 1% - 15% dei casi Bilateralità 33% Maggiore frequenza maschi 8,5% rispetto a femmine 4,9% Rx con margini netti wwwmarcospoliticom
  • 15. ALTERAZIONI SPAZIO SUB-ACROMIALE STRUTTURALI Os Acromiale 7 Potenziali Tipi di Os Acromiale wwwmarcospoliticom
  • 16. ALTERAZIONI SPAZIO SUB-ACROMIALE STRUTTURALI artrosi acromion - claveare Petersson CJ et al clin orthop 1983 Ruptures of the supraspinatus tendonthe significance of distally pointing acromio-clavicular osteophites PLASTICA CLAVEARE MINIMUMFORD wwwmarcospoliticom
  • 17. ALTERAZIONI SPAZIO SUB-ACROMIALE STRUTTURALI Osteofitosi del Leg. C-a Nicholson GP, Goodman DA, Flatow EL, Bigliani LU JBJS 1977 The acromion : Morphologic condition and age related changes a study of 420 scapulas Architettura acromion caratteristica anatomica primaria. Calcificazioni legamento C-A con formazione di “SPUR” in aumento con l’età wwwmarcospoliticom
  • 18. ALTERAZIONI SPAZIO SUB-ACROMIALE STRUTTURALI Degenerazione Intrinseca Cuffia “weakness of the supraspinatus compromises its function as a humeral head depressor” Codman 1934 Turbe del microcircolo - degenerazione intrinseca della cuffia alterazione dell’effetto delle coppie di forza - mancata depressione della testa -IMPINGEMENT (Ozaki 1988, Sarkar1990, Ogata1990, Uhthoff1990) wwwmarcospoliticom
  • 19. ALTERAZIONI SPAZIO SUB-ACROMIALE FUNZIONALI Discinesia scapolo-toracica Prossimale - primaria la causa è la SCAPOLA Distale – secondaria la causa è un deficit di cuffia – manca forza in rot est. wwwmarcospoliticom
  • 20. ALTERAZIONI SPAZIO SUB-ACROMIALE FUNZIONALI Capsulari Retrazione e rigidità capsula postero-inferiore - Lassità anteriore (over use syndrome) wwwmarcospoliticom
  • 21. ALTERAZIONI SPAZIO SUB-ACROMIALE FUNZIONALI Posturali Ipercifosi – scoliosi Alterazione della posizione e ritmo scapolare Alterazione dei rapporti dinamici wwwmarcospoliticom
  • 22. CLINICA ANAMNESI ESAME OBIETTIVO Ispezione a spalla nuda Palpazione Articolarità attiva e passiva Tests funzionali specifici di impingement: Neer sign , Neer test, arco doloroso wwwmarcospoliticom
  • 23. Imaging Rx Standard Outlet RM Artro RM wwwmarcospoliticom
  • 24. Imaging RM wwwmarcospoliticom
  • 25. • Imaging RM wwwmarcospoliticom
  • 26. TRATTAMENTO Conservativo Conflitto sintomatico 1-2 Assenza di rottura di cuffia 6 mesi Correzione discinesia Correzione difetti posturali Rinforzo mm cuffia Correzione Alterazioni Capsulari Chirugico Conflitto sintomatico stadio 2 Mancata risposta a tratt. conservativo Rottura cuffia dei rotatori RIMOZIONE CHIRURGICA DEL CONFLITTO ACROMIONPLASTICA ARTROSCOPICA wwwmarcospoliticom
  • 27. TECNICA CHIRURGICA ARTROSCOPICA Posizionamento del Paziente Portali Ispezione Gleno Omerale Ispezione Sotto Acromiale Borsectomia Valutazione del Conflitto Scheletrizzazione dell’acromion Acromion Plastica Ev Riparazione Cuffia wwwmarcospoliticom
  • 28. TECNICA CHIRURGICA ARTROSCOPICA Posizionamento del Paziente 60° HEAD BACK SEAT FOOT Shykar et Al 1988 Altchek e Warren 1988 wwwmarcospoliticom
  • 29. TECNICA CHIRURGICA ARTROSCOPICA Portali SKIN MARKING Soft spot classico 2 cm med./2-3 cm inf. Portale Antero- laterale e intermedio di Ellman 2-3 cm dal bordo ant.-lat acromion wwwmarcospoliticom
  • 30. TECNICA CHIRURGICA ARTROSCOPICA Ispezione Gleno Omerale wwwmarcospoliticom
  • 31. TECNICA CHIRURGICA ARTROSCOPICA Ispezione Sotto Acromiale Borsectomia Valutazione del Conflitto wwwmarcospoliticom
  • 32. TECNICA CHIRURGICA ARTROSCOPICA Scheletrizzazione dell’acromion Acromion Plastica Ev Riparazione Cuffia wwwmarcospoliticom
  • 33. TECNICA CHIRURGICA ARTROSCOPICA CUTTING BLOCK TECNIQUE Morrison DS - Bigliani LU, et al. Orthop Trans 1987 The clinical significance of variations in acromion morphology wwwmarcospoliticom
  • 34. TECNICA CHIRURGICA ARTROSCOPICA Scheletrizzazione dell’acromion Acromion Plastica Ev Riparazione Cuffia wwwmarcospoliticom
  • 35. CONCLUSIONI ACROMIONPLASTICA Neer 1972 Acromion Plastica Open (risultati ottimi in 15 casi su 16) Ellman 1985-1987 decompressione subacromiale artroscopica (ottimi risultati 88% dei casi) wwwmarcospoliticom
  • 36. CONCLUSIONI Incremento drammatico dell’acromionplastica nell’ultimo ventennio con L’avvento dell’artroscopia. Yu E , et al. ARTHROSCOPY 2010 Arthroscopy and the dramatic increase oin frequency of anterior acromioplasty form 1980 to 2005: an epidemiologic study. Da 3,3 per 100.000 persone a 19,0 per 100.000 (1980-2005) Non cambiamenti significativi di incidenza per sesso, età tipo di lesioni della cuffia. Contributo dell’avanzamento tecnologico nelle metodologie di imaging e nella conoscenza delle patologie della spalla. Vitale MA, et al JBJS Am 2010 The rising incidence of acromioplasty Stato di NewYork 1996 - 5.571 PROCEDURE 30,0 x 100.000 2006 -19.753 PROCEDURE 101,9 x 100.000 Aumento 254,4% Problematiche di natura economica (rimborzi assicurativi). wwwmarcospoliticom
  • 37. CONCLUSIONI CHIRURGIA FACILE MA PERICOLOSA. Il sacrificio indiscriminato dell’acromion causa alterazione dell’arco coracoacromiale e puo’ condurre in assenza di indicazione corretta,di eccesso o in assenza di cuffia alla perdita critica dell’effetto buffering e a una spalla pseudo paralitica . (Flatow et Al J Shoulder Elb Surg 1997) wwwmarcospoliticom
  • 38. CONCLUSIONI ACROMIONPLASTICA SI NO Quando ? Quanto ? 1. nella sindrome da conflitto resistente a trattamento conservativo 1. Acromionplastica anteriore limitata - sufficiente 2. decomprimere senza essere causa di potenziale translazione 2. Gesto da associare a riparazione della cuffia dei rotatori anterosuperiore Denard PJ, et al Orthopaedics 2010 Contact pressure and glenohumeral translation following subacromial Evidenza Artroscopica e Clinica di Conflitto. decompression: how much is enough 3. Giustificata nella necessità di ampliare lo spazio chirugico (beach chair position). wwwmarcospoliticom
  • 39. CONCLUSIONI UTILE PER LA DISPERSIONE IN SITU DI GROWGTH FACTORS. Randelli p, et al knee surg sports traumatol arthrosc.2009 Release of growth factors after arthroscopic acromionplasty “Significativa concentrazione nel fluido presente nello spazio sottoacromiale dopo acromionplastica rispetto al campione ematico di : TGF - beta 1, PDGF – AB , bFGF ” Controindicazioni assolute: 1. Rotture di cuffia irreparabili 2. impingement secondario 3. Acromion tipo 1-A wwwmarcospoliticom
  • 40. CONCLUSIONI J Bone Joint Surg Am. 2012 Practice patterns for subacromial decompression and rotator cuff repair: an analysis of the American Board of Orthopaedic Surgery database. Mauro CS, Jordan SS, Irrgang JJ, Harner CD. Between 2004 and 2009, 12,136 surgical procedures involving only arthroscopic or open subacromial decompression and/or rotator cuff repair were performed CONCLUSIONS: From 2004 to 2009, there was a significant shift throughout the United States toward arthroscopic rotator cuff repair and subacromial decompression among young orthopaedic surgeons, with sports medicine fellowship-trained surgeons performing more of their procedures arthroscopically than surgeons with other training. However, there was an increasing frequency of arthroscopic rotator cuff repair performed without subacromial decompression, and, overall, there was a decrease in the frequency of isolated arthroscopic subacromial decompression over time. wwwmarcospoliticom
  • 41. CONCLUSIONI J Bone Joint Surg Br. 2012 Arthroscopic subacromial decompression is effective in selected patients with shoulder impingement syndrome. Magaji SA, Singh HP, Pandey RK. A total of 92 patients with symptoms for over six months due to subacromial impingement of the shoulder, who were being treated with physiotherapy, were included in this study. While continuing with physiotherapy they waited a further six months for surgery. They were divided into three groups based on the following four clinical and radiological criteria: temporary benefit following steroid injection, pain in the mid-arc of abduction, a consistently positive Hawkins test and radiological evidence of impingement. Group A fulfilled all four criteria, group B three criteria and group C two criteria. A total of nine patients improved while waiting for surgery and were excluded, leaving 83 who underwent arthroscopic subacromial decompression (SAD). The new Oxford shoulder score was recorded pre-operatively and at three and 12 months postoperatively. A total of 51 patients (group A) had a significant improvement in the mean shoulder score from 18 (13 to 22) pre-operatively to 38 (35 to 42) at three months (p < 0.001). The mean score in this group was significantly better than in group B (21 patients) and C (11 patients) at this time. At one year patients in all groups showed improvement in scores, but patients in group A had a higher mean score (p = 0.01). At one year patients in groups A and B did better than those in group C (p = 0.01). Arthroscopic SAD is a beneficial intervention in selected patients. The four criteria could help identify patients in whom it is likely to be most effective. wwwmarcospoliticom
  • 42. CONCLUSIONI BMJ. 2012 Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. Holmgren T, Björnsson Hallgren H, Öberg B, Adolfsson L. A total of 102 patients CONCLUSION: A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study. wwwmarcospoliticom
  • 43. CONCLUSIONI Arthroscopy. 2012 The role of subacromial decompression in patients undergoing arthroscopic repair of full-thickness tears of the rotator cuff: a systematic review and meta-analysis. Chahal J, Mall N, MacDonald PB, Van Thiel G, Cole BJ, Romeo AA, Verma NN. CONCLUSIONS: On the basis of the currently available literature, there is no statistically significant difference in subjective outcome after arthroscopic rotator cuff repair with or without acromioplasty at intermediate follow-up. LEVEL OF EVIDENCE: Level I, systematic review of Level I studies. wwwmarcospoliticom
  • 44. Impingement is no calling it “Rotator C Muscles, Ligaments and Tendons Journal 2013; 3 (3): 196-200 Original article er na zio na li Impingement is not impingement: the case for calling it “Rotator Cuff Disease” Edward G. McFarland 1 Nicola Maffulli 2 Angelo Del Buono 3 George A. C. Murrell 4 Juan Garzon-Muvdi 1 Steve A. Petersen 1 1 Division of Depa As a result, we recommend that the spec- trum of rotator Shoulder Surgery, Hopk cuff thopaedic Surgery, The Johns abnormalities no longer be called “impingementfor a more Baltimore rather and Rehab disease”Department ofUSA but MD, Physical pathology is conceptualized allows Edward G. McFarland cine, University of Salerno School of comprehensive approach to the care of the paNicola Maffulli “rotator cuff dis- ease”. Surgery, Salerno, Italy. Centre for Sp tient with rotator cuff disease. Angelo Del Buono 2 1 2 3 George A. C. Murrell TheGarzon-Muvdi KEY will acromioplasty, scientific community London School of Med Juan term “rotator cuff dis- ease”WORDS:free the impingement, rotator Barts and The cuff, shoulder, tendinopathy surgery, treatment. Steve A. Petersen tistry, Mile from the re- straints of the limitations of the concept of “impinge-End Hospital, London, UK Department of Orthopaedic and Tra cise Medicine, Queen Mary Univers 4 1 1 3 1 Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore MD, USA Department of Physical and Rehabilitation Medicine, University of Salerno School of Medicine and Surgery, Salerno, Italy. Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK Department of Orthopaedic and Trauma Surgery, Campus Biomedico Universit y of Rome, Italy Orthopaedic Research Institute, University of South Wales, The St George Hospital, Sydney, Australia Campus Biomedico Universit y of Rom Orthopaedic Research Institute, Univ Wales, The St George Hospital, Sydn Introduction 4 The cause of rotator cuff conditions has been debated for more than 100 years. Theories include intrinsic tendon degeneration, vascular factors, tension overload, differential stress in layers of the tendon, and impingement syndromes. The latter has become synonymous with all rotator cuff conditions and rotator cuff disease in general. As a result, anterior and lateral shoulder pain is commonly described by many providers as “impingement”. However, rotator cuff disease is a condition with protean presentation and multifactorial intrinsic or extrinsic causes, and biologic, biomechanical, anatomical, and clinical information increasingly suggests that the theory of impingement often does not reflect the reality of the pathogenesis of rotator cuff disease. This commentary will Corresponding author: Edward G. McFarland c/o Elaine P. Henze, BJ, ELS, Medical rector, Editorial Services, Department o Surgery, The Johns Hopkins Universi kins Bayview Medical Center 4940 Eastern Ave, #A665, Baltimore 2780, USA E-mail: ehenze1@jhmi. edu 3 4 ni 2 In t ment” and will allow exploration of other causes and treatments. Corresponding author: Edward G. McFarland c/o Elaine P. Henze, BJ, ELS, Medical Editor and Di- wwwmarcospoliticom Summary
  • 45. www.marcospoliti.com wwwmarcospoliticom

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