shoulder•opsurg-shoulder-001

Acromioplasty

intermediate Level

Primary Indication

Subacromial impingement syndrome refractory to 3-6 months of conservative treatment (physiotherapy, NSAIDs, subacromial injection), or as part of rotator cuff repair to decompress the subacromial space

Danger Structures

Axillary nerve (5cm below lateral acromion)
Suprascapular nerve (medially at spinoglenoid notch)
Acromial branch of thoracoacromial artery
Deltoid origin
Rotator cuff (supraspinatus)
Long head of biceps

Visual Atlas

No anatomy Images Yet

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Step-by-Step Technique

Position in beach chair at 30-70° with head secured, arm in pneumatic arm holder

Surgeon's Tip

EXAM KEY: Beach chair allows easier conversion to open if needed. Ensure arm can be positioned in adduction for subacromial access.

Danger Zone

Hypotensive episodes in beach chair
Brachial plexus traction

Mark bony landmarks: acromion, AC joint, coracoid, and portal sites

Surgeon's Tip

EXAM KEY: Posterior portal 2cm inferior and 1cm medial to posterolateral corner of acromion

Danger Zone

Portal malposition
Axillary nerve injury with low posterior portal

Establish posterior viewing portal, perform diagnostic glenohumeral arthroscopy first

Surgeon's Tip

EXAM KEY: Always look in joint first - assess labrum, biceps, rotator cuff from articular side

Danger Zone

Missing intra-articular pathology
Iatrogenic cartilage damage

Document any rotator cuff tears, SLAP lesions, or other pathology before proceeding

Surgeon's Tip

EXAM KEY: Partial articular-sided cuff tears common - decide on debridement vs repair

Danger Zone

Missing pathology
Inadequate documentation

Redirect scope to subacromial space via posterior portal

Surgeon's Tip

EXAM KEY: Pass scope over top of rotator cuff into subacromial bursa - visualize bursal surface of cuff

Danger Zone

Scope tip damage to cuff
Loss of orientation

Establish lateral working portal 2-3cm distal to lateral acromion edge

Surgeon's Tip

EXAM KEY: Lateral portal gives perpendicular access to undersurface of acromion for efficient bone resection

Danger Zone

Axillary nerve at risk if >5cm distal to acromion
Inadequate working angle

Perform bursectomy to visualize acromion undersurface, coracoacromial ligament, and cuff

Surgeon's Tip

EXAM KEY: Good visualization essential before bone resection - can use shaver or electrocautery for bursa

Danger Zone

Incomplete bursectomy limiting visualization
Fluid extravasation

Identify acromial morphology (Type I flat, II curved, III hooked) and any spurs

Surgeon's Tip

EXAM KEY: Bigliani classification - Type III hooked associated with impingement and cuff tears

Danger Zone

Missing anterior spur
Over-resection causing fracture

Release coracoacromial ligament from undersurface of anterior acromion

Surgeon's Tip

EXAM KEY: CA ligament release is key for decompression - but preserve superior restraint to anterosuperior escape

Danger Zone

Incomplete release
CA arch violation in massive cuff tears (leads to escape)

Using arthroscopic burr, resect anterior-inferior acromion to flat (Type I) surface

Surgeon's Tip

EXAM KEY: Convert any Type II/III acromion to Type I flat configuration. Resect 5-10mm anteriorly.

Danger Zone

Over-resection causing weakness/fracture
Under-resection leaving impingement

Create smooth, flat undersurface from anterior to posterior edge

Surgeon's Tip

EXAM KEY: Bleeding bone edge confirms adequate resection. Use 70° scope from lateral portal to check.

Danger Zone

Uneven resection
Thermal necrosis from burr

Resect any acromioclavicular joint osteophytes projecting inferiorly (distal clavicle excision if needed)

Surgeon's Tip

EXAM KEY: Inferior AC joint osteophytes can contribute to impingement - may need 5-10mm distal clavicle excision

Danger Zone

AC joint instability from excessive resection
Missing AC joint pathology

Verify complete decompression by passing instrument under acromion with arm in adduction

Surgeon's Tip

EXAM KEY: Should pass shaver easily under acromion with arm at side - no bony block

Danger Zone

Residual impingement
Missing lateral acromion spur

Inspect rotator cuff from bursal side, treat any tears as indicated

Surgeon's Tip

EXAM KEY: Full-thickness tears need repair. Partial tears >50% may benefit from completion and repair.

Danger Zone

Missing bursal-sided tears
Inadequate cuff assessment

Irrigate subacromial space, remove loose bodies, close portals, apply dressings

Surgeon's Tip

EXAM KEY: Early ROM critical - sling for comfort only 24-48hrs, then progressive rehabilitation

Danger Zone

Stiffness from immobilization
Portal site infection