Acromioplastie : Techniques et Indications
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Safaa MedAcromioplastie : Techniques et Indications
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Safaa MedCommon questions
Alimenté par l’IAAdvantages of arthroscopic acromioplasty include preservation of the deltoid muscle, less pain, faster recovery, and more aesthetically pleasing results compared to open surgery. The exploration of intra-articular structures is also better with arthroscopy . However, disadvantages include the requirement for expensive single-use equipment .
Pre-operative imaging may include ultrasound, arthro-CT, MRI, or arthroscopy. These assessments are meant to rule out transfixiant rotator cuff ruptures, assess the shape of the acromion, and detect calcifications .
Primary indications for acromioplasty include tendinopathy of the supraspinatus at stage II, which is sufficiently painful (including nocturnal pain) and resistant to conservative treatments such as physiotherapy and corticosteroid injections. The patient must also be motivated and have normal passive mobility . Accessory indications include in the context of cuff repair, extensive non-repairable ruptures, partial and intra-tendinous ruptures, and other conflicts, although the utility in these cases has not been demonstrated .
Bigliani and colleagues classified acromion types into three categories: Type I (flat), Type II (curved), and Type III (hooked). Type III acromions are associated with a higher risk of subacromial impingement due to their shape, which can contribute to tendon wear and tear or even tears. The evolution with age and the development of anterior osteophytes can exacerbate these problems .
Less satisfactory outcomes can occur in patients who sustained work-related injuries, have a long history of painful pathology, experienced technical errors during surgery like insufficient resection or persistent osteophytes, or have concurrent acromioclavicular (AC) joint pain. Additionally, the progression of tendon diseases such as widespread calcifications and intra-tendinous ruptures can also lead to suboptimal results .
The condition of the acromioclavicular joint, if symptomatic, necessitates its consideration during acromioplasty. This is because symptoms like pain upon palpation and involvement in impingement syndromes require surgical intervention . If osteophytes from the AC joint extend and impinge on the rotator cuff, this warrants removal during surgery (coplaning) to alleviate conflict . A correct interpretation of the AC joint's impact can lead to additional approaches during the initial procedure to ensure optimal results .
Challenges include better understanding of aggressive acromion forms, determining the best treatment for partial ruptures, and discerning why some rotator cuffs progress to rupture despite adequate decompression . Other challenges involve addressing the evolution of tendinous diseases such as widespread calcifications and intra-tendinous ruptures, which affect surgical outcomes .
Post-operative pain management includes administration of long-lasting local anesthetics like Naropin in combination with morphine at the operative site on the same day . Additionally, aiding active restricted mobilization through analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and patient counseling about recovery time can help manage post-operative discomfort .
Immediate postoperative care involves administering long-acting local anesthetics in the subacromial bursa and starting passive mobilization the same day . Rehabilitation starts with regaining passive mobility followed by active exercises in physiotherapy, and self-assisted exercises at home . Patients should be informed that it takes at least three months to see the final results, and care should be taken to prevent rebound effects during the 4-6 week period for patients eager to progress .
The acromioclavicular joint should be addressed during acromioplasty if it is symptomatic, such as exhibiting elective pain upon palpation or involvement in impingement symptoms . If necessary, resection of the A-C joint is possible via a third anterior approach . The presence of inferiorly projecting osteophytes causing conflict with the rotator cuff may also necessitate intervention .