Shoulder Surgery

Subacromial Decompression and Acromioplasty

Subacromial Decompression and Acromioplasty

Arthroscopic subacromial decompression and acromioplasty is a minimally invasive keyhole procedure to treat shoulder bursitis, bone spurs and impingement symptoms. It is often done as a part of other keyhole procedures in the shoulder, such as a biceps tenodesis and rotator cuff repair. After an isolated arthroscopic subacromial decompression and acromioplasty a sling is worn for 1-2 weeks; and JPL therapy commences immediately after surgery. Strengthening is allowed at 4-6 weeks; and full unrestricted activity is possible at 6-12 weeks after surgery. This pathway may vary if other procedures are carried out at the same time.

This is a surgical procedure that is performed keyhole (arthroscopic) to remove the inflamed bursa and bone spur below the acromion. This is usually done as a day procedure or with an overnight stay, depending on what else is being addressed within the shoulder.

The keyhole procedure has some advantages compared to more traditional open methods of surgery (with larger incisions), they include:

  • Smaller incisions and better cosmesis
  • Less pain
  • Less blood loss
  • Better visualisation and ability to address other areas of concern
  • Faster recovery
  • Less post-surgery stiffness
  • Lower risk of infection

Medical diagram showing the anatomy of a shoulder joint and how the Arthroscopic Bone Burr is used to perform a Subacromial decompression and Acromioplastyd

The essential components that are treated during a subacromial decompression and acromioplasty are:

  1. Removal of the inflamed and thickened subacromial bursa
  2. Resection of the subacromial bone spur (shoulder spur)
  3. Release of the coraco-acromial (CA) ligament (almost always)

The other possible areas that may be simultaneously treated (either diagnosed on MRI prior to surgery or found at the time of arthroscopy):

  1. Acromioclavicular Joint (ACJ) resection (also called a distal clavicle resection)
  2. Rotator Cuff Repair
  3. Biceps tendon release (tenotomy) or re-anchoring (tenodesis) 
  4. Capsular Release (for adhesive capsulitis = frozen shoulder)

The procedure is performed under a General Anaesthetic where you will be positioned on your side and the affected arm secured in a special arm holder.

  • The shoulder is then prepared with a special antiseptic solution (dark pink in colour) and the surgical drapes are applied to maintain a sterile field at all times.
  • Small key-hole incisions (about 0.5-1cm) are made and the camera and surgical instruments are placed inside the shoulder.  Usually 3 small incisions are enough
  • A thorough 15-point examination of the shoulder joint is made via the arthroscopic camera and pictures are taken to document findings.

Biceps

  • The first step is to address biceps tendon if needed
  • The biceps tendon will either be moved out of the shoulder joint or re-anchored in the arm pit at the start of the case
  • The decision between these two options is made in the office and will be on your consent form prior to surgery.

Bone Spur and Bursa

  • Next, attention is turned to the area above the tendon and any bursitis is shaved away carefully and the bone spur is identified. A special 5.5mm metallic burr is then used to shave away the spur and create more room to allow the tendon to move freely. The CA ligament which is thickened and causing compression is also released.
  • The key-hole incisions are closed with sutures, dressings applied and a custom sling used to position the arm correctly (depending on your type of surgery).

Dr Pant will then organise close follow up at regular intervals and liaise with your Physiotherapist to maximise your recovery.

The outcome after a subacromial decompression and acromioplasty is generally excellent with surgical wounds barely visible ultimately. Patients commence therapy immediately after surgery using the JPL protocol. They can dispense with the sling after the first week or two and commence driving after the wound review appointment (at 2 weeks). The only exception to this is if a Rotator Cuff Repair or Biceps tenodesis has been carried out – in which case a sling is worn for six weeks and driving commences at 6-8 weeks.

There are three essential components to a good outcome from surgery

  • Your surgeon
  • You as a patient
  • Your physiotherapist

Post-operative physiotherapy

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.

The JPL pathway allows for self-directed, early passive shoulder range of movement:

  • Passive = assisted with your other arm
  • Active = you move the affected arm independently

Therapy overview 

After the surgery you will be in a sling and protect your shoulder to allow the shoulder to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.

The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the shoulder begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 4-6 weeks post isolated subacromial decompression and acromioplasty surgery.

Sling

  • A sling is required for the first 2-6 weeks after your surgery
  • In some instances you may only need a sling for 1-2 weeks – Dr Pant will discuss these cases with you.

The type of sling is selected specific to you and your shoulder surgery

  • Subacromial Decompression +/- Biceps tenotomy/tenodesis – Normal sling

Driving after shoulder surgery

  • After shoulder surgery you will be in a sling and you may be unable to drive
  • This does vary depending on the complexity of your surgery and the patient. Some patients may be able to drive at 2 weeks; and some may not be able to drive for the full 6-12 weeks. This will be discussed at your follow up appointments.

Showering and getting dressed

  • You may take the sling off to shower
  • Lean forward and allow your arm to “dangle” to wash under your arms
  • The dressings applied are waterproof and you may shower with them on
  • Usually, before you are discharged from Hospital, your dressings are changed after your morning shower.
  • These “new” dressings are then kept intact until your review at 10-14 days
  • If the dressings start to peel at the edges – you may reinforce them
  • If the dressings discolour with discharge (yellow or green) you may have a wound infection; do not be alarmed just yet – please notify SSU (02 9215 6100 or admin@drpant.com.au) and we will give you a plan.
  • When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery (especially after rotator cuff repair)
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 4-6 weeks after surgery. You should keep your sling on while asleep.

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the skin
  • The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications.

The risk of complications after arthroscopic subacromial decompression and acromioplasty surgery are less than 1% in the Sydney Shoulder Unit experience. General risks include:

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating to arthroscopic subacromial decompression and acromioplasty surgery:

  • Frozen shoulder (5% risk). Improves over 3-6 months and will generally not affect your outcome or need further surgery.
  • Reoperation and failure of surgery. When performing an arthroscopic subacromial decompression and acromioplasty, there is a small chance that the brusa may become inflamed again and the bone spur may reform. If the symptoms return there is a small chance of needing to repeat the procedure; the chance of this is less than 1% in the SSU experience.

Patients who smoke, use tobacco products, have diabetes, or are elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone healing.

Most healthy patients, however, cope well with keyhole shoulder surgery and are unlikely to have complications.

Patient results

AC Joint Arthritis

This 48 year old gentleman presented with pain over the top of his shoulder over many months. A diagnosis of AC Joint arthritis was made and he responded well to an ultrasound guided cortisone injection initially. However, that wore off over a few months and he was unable to sleep on the affected shoulder and very keen to get back to his active lifestyle, so he elected to proceed with surgery.

He underwent an Arthroscopic Acromioclavicular Joint (ACJ) excision via 3 small keyhole incisions. His procedure was routine, he stayed overnight in hospital, and was discharged home the following morning with oral painkillers.

He commenced immediate range of motion and discarded his sling between 1 -2 weeks after surgery. At three months, he is back to the gym and kayaking and is happy with his outcome; his keyhole incisions were only barely visible at the 3 month follow up.

Arthroscopic AC Joint excision is a very successful operation when non-surgical measures have been exhausted.

Rotator Cuff Tear

This 53 year old lady presented with right-sided shoulder pain after injuring her shoulder at work. She underwent a period of rest, cortisone injection and 3 months of physiotherapy without improvement.

After a careful history and examination, an MRI scan was undertaken. The MRI showed a Rotator Cuff Tear with Biceps Tendonitis.

The images taken at surgery (key-hole) demonstrate significant biceps tendonitis with inflammation and thickening of the tendon. The biceps tendon was taken out of the shoulder joint and re-anchored under the arm-pit (biceps tenodesis). The bursitis and bone spur was cleaned out and the rotator cuff tear was repaired with 4 anchors with good compression of the tendon foot-print.

She was discharged home the following day after surgery and placed in a sling for six weeks. She underwent JPL rehab which commenced at two weeks post-surgery. Strengthening commenced at months under the guidance of her physiotherapist.

She no longer has her previous shoulder pain and has good power of her rotator cuff.

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