Open Acromioplasty

Principles

“Two Step” Acromioplasty

  • 1st step
    • anterior acromioplasty to prevent impingement in flexion
    • Resect anterior acromion back to ACJ
  • 2nd step
    • resect anteroinferior acromion as per Neer

Position

  • Beach chair/semi-upright position with head elevated 30 to 35°
  • Regional Anaesthesia
    • provides excellent postoperative analgesia
  • Place iv bag medial to scapula
  • Drape arm free to permit full rotation
  • Perform EUA
    • Range of motion
      • if restricted → manipulate
    • Stability

Landmarks to outline

  • Lateral acromion, coracoid, acj
  • Outline proposed incision

Incision

  • 7 cm transverse curvilinear incision
  • From lateral to acromion towards point just lateral to coracoid

Superficial Dissection

  • Through fat
  • Expose Deltoid to ACJ
  • Find fibrous anterior raphe at anterolateral corner acromion which marks anterior & lateral parts of deltoid

Deep Dissection

  • Split raphe 3cm distally & along superior acromion in shape of “Y”
    • <5cm from acromion border to avoid axillary nerve
  • Detach Deltoid from acromion anterior to ACJ at fibrous insertion to allow repair
  • Resect CA ligament using diathermy (due to presence of acromial branch of C/A artery) hence exposing SA space
  • Place retractor under acromion to protect cuff
  • Identify raphe between anterior & middle deltoid & split it distally ()
  • Resect SA bursa along with all adhesions

Acromioplasty

  • 2 stage acromion resection with burr | saw | osteotome
    • 1. Use saw or osteotome to remove acromion anterior to anterior border of clavicle
    • 2. Remove anteroinferior acromion to junction of anterior & middle thirds (use blunt hohmann to protect cuff during osteotomy)
      • Smooth out any rough surfaces with  rasp
    • 3. Palpate undersurface of acj & remove any bone spurs or resect distal 1 to 1.5cm of lateral clavicle if severe degenerative changes present
  • Inspect cuff & repair defects
    • Abduct & Rotate
  • Ostectomies

Optional

  • Resect distal 2cm clavicle if Osteoarthritis
    • < 4% of patients
    • Only if pain referable to ACJ
    • Confirmed by LA to joint
  • Biceps tenodesis if > 50% torn

Closure

  • Reattach deltoid to acromion via drill holes & nonabsorbable sutures
  • Suture deltoid split from side to side
  • Close wound in layers

Postoperative

  • Sling for comfort
  • Pendular exercises day 1
  • Passive R.O.M. exercises at 1/52
  • Active R.O.M. exercises at 3/52

Complications/dangers

  • Anterior deltoid dysfunction
    • Axillary nerve injury
    • Detachment of deltoid from acromion
  • Synovial fistula
  • Acromial fracture