Settling the Controversy of Acromioplasty During Rotator Cuff Repair

Commentary The classic article in which Charles Neer first described his hypothesis that anterolateral acromial impingement is a causative factor in the development of rotator cuff tears set forth a dogma that still remains controversial 50 years after its publication1. Acromioplasty with resection of the undersurface of the anterolateral acromion along with the coracoacromial ligament was believed to prevent impingement of the bone on the underlying supraspinatus tendon. Woodmass et al. have provided long-term follow-up on a previously published patient population who were randomized to undergo rotator cuff repair with or without acromioplasty. The authors found no clinically important difference between groups with respect to patient-reported outcomes (specifically Western Ontario Rotator Cuff [WORC] scores or range of motion), which were maintained at a long-term follow-up, which averaged 11.2 ± 2.4 years for the group without acromioplasty and 11.5 ± 2.6 years for the acromioplasty group. Despite these findings, there was a higher reoperation rate seen in those subjects who underwent rotator cuff repair without acromioplasty, especially those with a Type-2 or 3 acromion. There have been several studies that have questioned the efficacy of and need to perform an acromioplasty during rotator cuff repair. Over the past 10 years, multiple Level-I and II systematic reviews and meta-analyses2-4 as well as randomized controlled trials5 have shown no difference in patient-reported outcomes or retear rates with follow-up of <8 years. Most of these studies had follow-up of 2 years and demonstrated no significant difference in the need for reoperation. The new overall understanding has been that acromioplasty does not influence the outcomes or results of rotator cuff repair in the short or intermediate term. Waterman et al.5 reported a mean 7.5-year follow-up of a randomized trial of subjects who underwent rotator cuff repair with or without acromioplasty, with no significant differences in American Shoulder and Elbow Surgeons (ASES) scores, Constant scores, University of California Los Angeles (UCLA) scores, or visual analog scale (VAS) pain scores. Waterman et al. demonstrated no difference in retear rates (2 subjects in the acromioplasty group and 3 subjects in the group without acromioplasty, all of whom underwent revision repair) or patient-reported outcomes when subgroups were analyzed by acromial morphology. The current thinking with regard to mechanisms of degenerative rotator cuff tearing involves the concept of both extrinsic and intrinsic factors. The morphology of the acromion was believed to have an impact on extrinsic rotator cuff tearing based on the degree of subacromial impingement. Over time, understanding the role of the scapular position has made our understanding how degenerative rotator cuff tears develop much more complicated. In the current study, Woodmass et al. begin to uncover a trend at longer-term follow-up that demonstrates that there is a higher incidence of reoperation in patients with a Type-2 or 3 acromion. There are several unanswered questions for which the authors do not provide data, including the incidence of retear and/or failed repair in the entire group. The bias toward only the subjects who were symptomatic and required reoperation does not provide a complete understanding of the entire cohort. The authors only have 65% follow-up, which leaves one-third of the subjects with unknown outcomes. Future prospective cohort studies with long-term follow-up are needed of patients undergoing rotator cuff repair without acromioplasty with a Type-2 or 3 acromion to determine what the true impact of the acromial morphology is on tendon healing and failure rates. The data from this investigation reopen the discussion of what the utility of an acromioplasty is during rotator cuff repair and actually pose more questions than answers. Given that the authors found no difference in patient-reported outcomes or shoulder function between groups, for patients who underwent reoperation, it is uncertain what their presenting symptoms were prior to the reoperation. Additionally, as it has been well documented that structural healing following rotator cuff repair does not correlate with outcomes, why did these subjects undergo reoperation other than to repair a rotator cuff retear?

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