Marco Spoliti Ortopedico illustra acromionplastica e decompressione sub acromiale in una conferenza sull' artroscopia ortopedica di spalla e ginocchio

1. DECOMPRESSIONE SUB-ACROMIALE
M. SPOLITI
U.O.C. DI CHIRURGIA ORTOPEDICA
Az.Osp. SAN.CAMILLO-FORLANINI
ROMA
Primario: Prof. S. Rossetti
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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
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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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lated RC tendon changes are more common in dianificant difference in the mi
29. Diabetic patients show a restricted shoulder
Yergason test are useful to assess the long head bi- compared wit
betics
of the tear
range of motion, higher incidence in retears the
there of
ceps9,11. Murrel and Walton compared after a resultswas increased vasc
surgical repair, and higher rate of complications and
from the tear42. Moseley a
12. Patients affected
23 commonly used shoulder tests
lary distributions in cuff s
infections are reported both after open and arthro30,31 . An association between
scopic repair of RCT
Review for supra- Via1
Alessio Giai
by shoulder pain, and who tested positivearticle that no hypovascular area
32 . ConMauro De vessel
obesity and RCTs has also been proposed
that both Cupis1 diameter
Marco Spoliti2
Clinical genital subacromial stenosis of a rare abnormality of
and biological aspects is rotator cuff tears
mately reduced by a third a
Francesco Oliva1
Clinical and biological aspects of rotator cuff tears
the subacromial arch and may predispose to impingecompared with 30 mm, bu
Muscles, ment 33.
Ligaments and Tendons Journal 2013; 3 (2): 70-79 exist 44. Indeed
cular areas of Orthopaedic and Tra
1 Department
Table 1. Extrinsic and intrinsic theories about etiopathogenesis of rotator cuff tears (RCTs). chemicalofand intraoperativ
versity
Rome „„Tor Vergata”, Sch
Currently RCTs are considered to be multifactorial in
Rome, Italy
etiology, and the References contributions of these facrelative by first
sis 2 reported of Orthopaedics and
Department relative hyperp
Theory
1
2. Two prospective studies, one Year
Alessio Giai Viators remain to be determined. 5 to 30%
ing from Soslowsky, in his study perSan zone, 45 and laser
critical Camillo-Forlanini Hospital, Rom
Mauro De Cupis1
formed with Magnetic Resonance Imaging (MRI) and
showed hyperaemic resp
Marco Spoliti2 on animal model, observed that the role of extrinsic the
the other factors
Extrinsic with ultrasonography, investigated
Francesco Oliva1
prevalence of RCTs in individuals without pain and
Corresponding data
compression or overuse with apparently normal function. In the first study, tear46. These author: sugges
factors without an additional
Francesco Oliva
Chronic impingement syndrome
Neer
1972
Sher
al. reported that 28% of patients older
factor may be insufficient toetcause tendinopathy and than tear is not ofhypovascular,
Department Trauma and Orthopae
1 Department of Orthopaedic and Traumatology, Uni3 . In the second
60 years had a full-thickness tear
University of Rome “Tor Vergata”
Codman Milgrom a type ultrasonographic prevathat an extrinsic compression, like reported anIII acromion, 1931, that the avascularity of the
versity of Rome „„Tor Vergata”, School of Medicine,
study
Overuse
School of Medicine
McMaster of 65% of RCTs in patients older than 704. In
1993
Rome, Italy
lence
did not cause injury of the RC tendonsa until on cadaveric and tifact of techniques used d
overuse
2 Department of Orthopaedics and Traumatology,
Viale Oxford, 81
2006 Reilly published review
42.
San Camillo-Forlanini Hospital, Rome, Italy
Multifactorial
Soslowsky
activity was introduced 34imaging prevalence of RCTs5. The overall prevalence ies00133 Rome, Italy
. More recently the prepon- 2004
was 23% in 4629 cadaveric shoulders. The prevae-mail: olivafrancesco@hot mail.com
derance of evidence strongly RCTs increases that extrinsic the More than seventy years a
lence of suggests linearly with age from
Intrinsic factors
Corresponding author:
acromial compression is thirdaccordingprimary. cause of 55% in the generative theory for RCT
notdecade, rising from 33% in the 40s to RC
the to Milgrom4
Francesco Oliva
50s
Summary
Hypoperfusion theory
Uhthoff
Department of Trauma and Orthopaedic Surgery and cadaveric studies have found 1990 portance of degenerative
pathology. Clinical
University of Rome “Tor Vergata”
Rotator cuff tears are common and
that the
School of Medicine theory majority of pathologic changes occur on the 1999 pathogenesis of tendon te
Physical examination
Degenerative
Sano
source of shoulder pain and dis
Viale Oxford, 81 articular side of the supraspinatus and infraspinatus
currently inconfirmed. of rot
variation
the prevalence His
00133 Rome, Italy
The clinical diagnosis is not always easy. Painful conDegeneration-microtrauma
Yadav
35 . This 2009 stumps of reported. The etiology
has been torn RCTs and
e-mail: olivafrancesco@hot mail.com
tendon insertions, awayditions of the long acromion acromioclavicular
from the head biceps6 or
tear remains multifactorial and at
joint may result in high false 36
positive rate7. The clinifinding was confirmed by presentation of et al. (RC) pathology is2002 ning and and extrinsic theoriesof c
Apoptotic theory
Yuan Buddoff rotator cuff . He also excal
intrinsic disorientation trie
Summary
etiopathogenesis of rotator cuff te
supposed that once RC tremely variable. A recent review concluded that generation, hyaline degene
damage and weakness ocRCTs are frequently asymptomatic7. Such variation in
of the etiopathogenesis of rotator
Extra cellular matrix modifications
Riley
2002
curs, the tendons are
sia, calcification, our therapies
Rotator cuff tears are common and are a frequentunable to effectively oppose the anclinical features is a question that remains to be
portant to improve vascular
source of shoulder pain and disability. A wide
swered. Physical examination should include inspecniques and promote tendon repair
variation in the prevalence of rotator cuff tears
tion, palpation, the evaluation of active and passive
gies have been proposed to enhan
has been reported. The etiology of rotator cuff
range of motion, the execution of strength and
ing and recently research has Ten
Muscles, Ligaments and foc
tear remains multifactorial and attempts to unify
provocative tests. While strengthstructural failure after RC repair is a
spinatus weakness, weakness in external rotation,
Rerupture or may be normal in
72
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5. DECOMPRESSIONE SUB-ACROMIALE
SINDROME DA CONFLITTO SUB-ACROMIALE
CONFLITTO TRA CUFFIA E ARCO CORACO ACROMIALE
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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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9. DECOMPRESSIONE SUB-ACROMIALE
ANATOMIA ARTROSCOPICA SPAZIO SUB-ACROMIALE
Matthews & Fadale Arthroscopy 1989
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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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11. ALTERAZIONI SPAZIO SUB-ACROMIALE
STRUTTURALI
FUNZIONALI
Forma dell’acromion
Discinesia scapolo-toracica
Spessore dell’acromion
Capsulari
Os Acromiale
Posturali
Osteofitosi del Leg. C-a
Degenerazione Intrinseca Cuffia
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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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15. ALTERAZIONI SPAZIO SUB-ACROMIALE
STRUTTURALI
Os Acromiale
7 Potenziali Tipi di Os Acromiale
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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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19. ALTERAZIONI SPAZIO SUB-ACROMIALE
FUNZIONALI
Discinesia scapolo-toracica
Prossimale - primaria la causa è la SCAPOLA
Distale – secondaria la causa è un deficit di cuffia – manca forza in rot est.
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20. ALTERAZIONI SPAZIO SUB-ACROMIALE
FUNZIONALI
Capsulari
Retrazione e rigidità capsula postero-inferiore - Lassità anteriore
(over use syndrome)
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21. ALTERAZIONI SPAZIO SUB-ACROMIALE
FUNZIONALI
Posturali
Ipercifosi – scoliosi
Alterazione della posizione e ritmo scapolare
Alterazione dei rapporti dinamici
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22. CLINICA
ANAMNESI
ESAME OBIETTIVO
Ispezione a spalla nuda
Palpazione
Articolarità attiva e passiva
Tests funzionali specifici di impingement:
Neer sign , Neer test, arco doloroso
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23. Imaging
Rx Standard
Outlet
RM
Artro RM
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24. Imaging
RM
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25. • Imaging
RM
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26. TRATTAMENTO
Conservativo
Conflitto sintomatico 1-2
Assenza di rottura di cuffia
6 mesi
Correzione discinesia
Correzione difetti posturali
Rinforzo mm cuffia
Correzione Alterazioni Capsulari
Chirugico
Conflitto sintomatico stadio 2
Mancata risposta a tratt. conservativo
Rottura cuffia dei rotatori
RIMOZIONE CHIRURGICA DEL
CONFLITTO
ACROMIONPLASTICA ARTROSCOPICA
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27. TECNICA CHIRURGICA ARTROSCOPICA
Posizionamento del Paziente
Portali
Ispezione Gleno Omerale
Ispezione Sotto Acromiale
Borsectomia
Valutazione del Conflitto
Scheletrizzazione dell’acromion
Acromion Plastica
Ev Riparazione Cuffia
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28. TECNICA CHIRURGICA ARTROSCOPICA
Posizionamento del Paziente
60°
HEAD
BACK
SEAT
FOOT
Shykar et Al 1988
Altchek e Warren 1988
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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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30. TECNICA CHIRURGICA ARTROSCOPICA
Ispezione Gleno Omerale
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31. TECNICA CHIRURGICA ARTROSCOPICA
Ispezione Sotto Acromiale
Borsectomia
Valutazione del Conflitto
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32. TECNICA CHIRURGICA ARTROSCOPICA
Scheletrizzazione dell’acromion
Acromion Plastica
Ev Riparazione Cuffia
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33. TECNICA CHIRURGICA ARTROSCOPICA
CUTTING BLOCK TECNIQUE
Morrison DS - Bigliani LU, et al. Orthop Trans 1987
The clinical significance of variations in acromion morphology
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34. TECNICA CHIRURGICA ARTROSCOPICA
Scheletrizzazione dell’acromion
Acromion Plastica
Ev Riparazione Cuffia
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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.
wwwmarcospoliticom

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

45. www.marcospoliti.com
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