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
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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.
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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.
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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
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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.
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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
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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
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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
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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
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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
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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)
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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
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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)
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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).
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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)
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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).
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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
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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.
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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.
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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.
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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.
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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-
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Summary