FIG. 1 43f; THE JOURNAL OF B NE ANI) JOINT SURGERY EXCISION OF THE ACROMION IN TREATMENT OF THE SUPRASPINATUS SYNDROME Report of Ninety-five Excisions * J. R. ARMSTRONG, LONDON, ENGLAND The majority of patients who complain of a painful shoulder are suffering either from periarthritis, ‘ ‘ frozen shoulder, ‘ ‘ or from a supraspinatus lesion. Lesions of the supraspinatus tendon at or close to its insertion, where it is intimately associated with the subacromial bursa, give rise to a characteristic combination of symptoms-the supraspinatus syndrome -which are mechanical in origin. In the middle range of abduction movement the tendon impinges on the overlying lrocesses and the tendon and bursa are compressed between t he humerus and acromion (Fig. 1). When there is abnormality of the tendon or bursa this pressure causes pain, anti any movement which tends to bring the lesion into contact with the acromion causes reflex muscle spasm. The supraspinatus syndrome is usually character- istic, although in its later stages it may be complicated by true limitation of shoulder movement, due partly to disuse and partly to adhesion formation in the region of the sub- acromial b rsa, vhich masks the typical symptoms and complicates both diagnosis and treatment. In the middle range of abduction the supraspinatus tendon and subacromial bursa are compressed between the upper end of the humerus and the acromion. The results of conservative treatment-Most patients with he supraspinatus syndrome recover either spontaneously or after conservati e treatment. Many measures have been advocated and good resul s have been reported with each of them. It is probably true that about 90 per cent. of patients with this condition get well in a few weeks. In the remaining 10 per cent., symptoms persist stubbornly for many months in spite of such treatment as rest, hysiOthera y, manipulation, active exercises, infiltration with local anaesthetic or deep X-ray therapy, and it is in this group of cases that excision of the acromion is ndicated. THE AIMS AND PRINCIPLES OF EXCISION OF THE ACROMION The principle underlying excision of the acromion is simple. Intermittent pressure associated with abduction or forward flexion of the arm causes pain and muscle spasm, and constantly repeated irritation prevents healing of the lesion. Excision of the a romion relieves this pressure. A full range of painless shoulder movement then becomes possible and most of the symptoms disappear by the time the patient has recovered from the immediate effects of the c)peration. \Vhen relieved of irritation, the underlying condition slowly resolves or heals. Based on a paper read at 1/ic .1 nnual 1Ieeting of the British Orthopaedic Association in elfast, October 1948
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EXC IS ION OF THE ACROM ION IN TREATM EN T OF THE SUPRA SP INA TU S SYN DROM E 43 9
IND ICAT IONS FOR EXC ISION OF THE ACROM ION
B ro ad ly speak ing , exc ision of th e acrom ion is ind ica ted in treatm en t o f the suprasp ina tus
synd rom e w henever conserva tive trea tm en t has fa iled . M ore prec ise ind ica tions vars’
accord in g to ind iv idua l op in ion and they d epend upon a num ber of c ircum stances. T he m ost
im portan t s ing le fac to r is the du ra tion of sym ptom s. L esio ns o f the su prasp ina tus g rou p
ten d to re so lv e and su bside w ith tim e , and op era tion is never a m atte r o f u rgency . Ind eed
som e surg eo ns m ain ta in tha t a ll these lesions recover spon tan eo usly ov er a period of one or
tw o yea rs ; bu t ev en if th is w ere tru e , w h ich is to be d oub ted , few p atien ts are p rep ared to
to le ra te sym ptom s fo r so long a tim e , n o r is it rea so nab le to expec t them to do so . O n the
o the r hand it is im poss ib le to te ll in the ea rly stag es w h ich pa tien t w ill reco ve r an d w hich
w ill req u ire op era tion . C on serva tive treatm en t shou ld a lw ay s b e tried fo r a t lea st tw o m onths;
and on ly if th e re is no im prov em en t a t the en d of tha t tim e sh ou ld ope ratio n be cons ide red .
\\‘hen , as is o ften the case , sym ptom s im p rove to som e ex ten t w ithou t b ein g com ple te ly
re lieved , o th er fac to rs m u st d ete rm ine w heth er o r no t op era tion sho u ld be adv ised . Th e
severity o f the sym ptom s and the d eg ree o f assoc ia ted d isab ility a re o bv ious ly im por tan t.
In its in itia l stages the acu te syn drom e m ay be acu te ly pa in fu l an d cripp ling , bu t th is ph ase
does no t o f ten pers ist. T h e typ ica l syndrom e is ne ithe r v ery pa in fu l no r com ple tely
incapacita ting and its e ffec ts o ften depend on the age , occupa tion an d m ode of life o f th epa tien t. A p ain fu l a rc o f m ov em en t m ay be no m o re than a m ild nu is an ce to an e lde rly
pa tien t o f s ed en tary hab its and ye t b e a seve re h an d icap to a y ounge r pe rson w hose
occupa tio ns a re strenuo us. D iscom fort, a ccep ted ph ilo sop h ically by one w ith a ph legm a tic
tem peram en t, m ay be devas ta ting in its e ffec ts on a m ore h igh ly strung pa tien t. E ach
pa tien t w ho does no t respond to conserva tive trea tm en t p rov ides an ind iv idu al p ro b lem ;
and the su rg eo n’s a ttitud e to op era tion w ill ce rta in ly be in fluen ced pro fo und ly b y h is o p in ion
of its e fficacy .
There are tw o c ircum stances in w h ich ex cisio n of the ac rom ion is co n tra- ind ica ted . \V h en
there is true lim ita tio n of shou ld er m ovem ent, o pera tion p rodu ces a stiff and s tu bborn jo in t
w h ich requ ires m onths of trea tm en t befo re m obility is resto red . M usc le sp asm can be d is tin -
gu ished from adhesion fo rm ation by exam in a tion afte r th e lesion has b een in f iltra ted w ith
loca l an aes the tic o r, be tter s till, by exam ina tion under a g en eral anaes th e tic . I f the re is true
lim ita tio n th is m ust b e dea lt w ith by active ex ercises, an d perhaps m an ipu la tion , be fo re
opera tion is co n tem p la ted . O pera tion is a lso con tra -ind ica ted if the re is d oub t as to th e
d iag nos is . R em ova l o f the aG rom ion w ill re liev e p ressu re on the su prasp in atus ten don or
sub acrom ia l bursa bu t if app lied in a h ap hazard m anner to the trea tm en t o f a ll stiff p ain fu l
sho u lders th e o pera tio n g iv es very unsa tis facto ry resu lts , pa rticu la rly in pa tien ts vith
periarthritis.
RESULTS
In 1939 , W ’atson-Jones first repo rted exc ision of th e acrom ion in th e trea tm en t o f
suprasp ina tus tend on les io ns a t a m ee ting o f the B ritish O rth opaed ic A ssoc ia tion in
O sw estry ; a nd he desc ribed th e pro ced ure in 1943 . A t abou t tha t tim e th is w rite r w as b ecom ing
in creas ing ly d issa tis fied w ith the resu lts o f conserva tiv e trea tm en t in m any serv ice pa tien ts
w ho w ere und er trea tm en t a t the R oya l A ir Force H osp ital, R au ceb y . T ho se w ho w ere no t
p rom ptly re lieved by co nserv ative trea tm en t w ere o ften incapac ita ted fo r lon g periods an d
there seem ed no th ing e lse to offer . A fte r trial o f exc ision of the acrom ion the resu lts w ere
encourag in g , p articu la rly w hen ex perien ce h ad sh ow n tha t it w as n ecessa ry to exc ise th e w hole
of the acrom ion . C onv ic tion tha t the opera tion w as a good one w as s tren g thened by persona l
experience . In 1944 , a fte r severa l m on th s o f ty p ica l incap acity w hich had pers isted unchang ed
d esp ite a ll fo rm s of co nserv ative trea tm en t, m y ow n acrom ion p rocess w as ex cis ed by S ir
R eg in ald W atso n-Jones w ith com ple te and perm anen t cu re . T he resu lts in a persona l se ries