shoulder•opsurg-shoulder-001-upper-limb-GRADE-A-2
Acromioplasty
intermediate Level
Primary Indication
Treatment of impingement syndrome; Failure of conservative treatment for 6-12 months; Recurrent symptoms; Associated with rotator cuff surgery
Danger Structures
- undefined - Travels through quadrangular space, runs around surgical neck of humerus 5-7cm inferior to lateral acromion edge (mean 6.5cm)
- undefined - Lies in deltopectoral groove lateral to incision; may cross operative field in subcutaneous tissue
- undefined - Runs within coracoacromial ligament substance; supplies anteroinferior acromion and deltoid
- undefined - Directly deep to acromion undersurface; 5-10mm distance from subacromial bursa to cuff in normal shoulder
- undefined - Forms roof of shoulder; anterior acromion is surgical target
- undefined - Passes through suprascapular notch beneath superior transverse scapular ligament, then around spinoglenoid notch; supplies supraspinatus and infraspinatus
- undefined - Passes between anterior and middle scalene muscles, enters axilla posterior to clavicle; no direct surgical risk but susceptible to stretch injury from positioning
Visual Atlas
Step-by-Step Technique
1
OPEN TECHNIQUE - Patient Positioning and Draping: Beach chair position, head elevated 30-35°, IV bag/sandbag under medial scapula to stabilize shoulder. Arm draped free allowing full range of motion. Mark bony landmarks: acromion, AC joint, coracoid. Prepare skin with chlorhexidine/betadine. Apply sterile drapes. EXAM KEY: Proper positioning prevents brachial plexus traction injury and optimizes surgical exposure.
Surgeon's Tip
EXAM KEY: Proper positioning prevents brachial plexus traction injury and optimizes surgical exposure.
Danger Zone
- Iatrogenic injury to adjacent structures
2
Incision and Deltoid Exposure: 5cm longitudinal incision centered over anterior acromion, starting at AC joint extending distally. Deepen through subcutaneous tissue and identify deltoid fascia. Use sharp dissection to minimize tissue trauma. EXAM KEY: Longitudinal incision follows Langer's lines and provides better cosmesis than transverse incision.
Surgeon's Tip
EXAM KEY: Longitudinal incision follows Langer's lines and provides better cosmesis than transverse incision.
Danger Zone
- Skin necrosis from excessive tension
- Damage to underlying structures
3
Deltoid Split - Identify and Protect Axillary Nerve: Palpate raphe between anterior and middle deltoid fibers. Split deltoid in line with fibers, extending NO MORE than 5cm distal to lateral acromion edge to avoid axillary nerve injury. Use blunt-tipped scissors or finger dissection. EXAM KEY: Axillary nerve lies 5-7cm inferior to lateral acromion edge - stay proximal to this zone.
Surgeon's Tip
EXAM KEY: Axillary nerve lies 5-7cm inferior to lateral acromion edge - stay proximal to this zone.
Danger Zone
- Nerve injury
- Neuropraxia
4
Deltoid Detachment from Anterior Acromion: Sharply detach anterior deltoid origin from acromion using electrocautery or scalpel, preserving periosteum with muscle for later repair. Extend detachment to AC joint medially. Tag deltoid edge with suture for later identification. EXAM KEY: Subperiosteal dissection preserves bone quality for secure reattachment with drill holes.
Surgeon's Tip
EXAM KEY: Subperiosteal dissection preserves bone quality for secure reattachment with drill holes.
Danger Zone
- Iatrogenic injury to adjacent structures
5
Coracoacromial (CA) Ligament Resection: Identify and excise CA ligament from anterior acromion using electrocautery. Ligate or cauterize acromial branch of thoracoacromial artery within ligament to prevent postoperative bleeding. EXAM KEY: CA ligament is part of coracoacromial arch - its resection alone may relieve impingement in some cases (Neer's principle).
Surgeon's Tip
EXAM KEY: CA ligament is part of coracoacromial arch - its resection alone may relieve impingement in some cases (Neer's principle).
Danger Zone
- Vascular injury
- Hemorrhage
6
Subacromial Bursal Resection: Excise inflamed, thickened subacromial bursa using rongeurs, scissors, or cautery. Remove all adhesions between bursa and rotator cuff to allow clear visualization of acromion undersurface and cuff. EXAM KEY: Bursal hypertrophy is a consequence, not cause, of impingement - but removal improves visualization.
Surgeon's Tip
EXAM KEY: Bursal hypertrophy is a consequence, not cause, of impingement - but removal improves visualization.
Danger Zone
- Iatrogenic injury to adjacent structures
7
Acromial Osteotomy - Anteroinferior Resection: Use oscillating saw or 10mm osteotome to remove 5-8mm of anteroinferior acromion. Resect bone anterior to anterior border of clavicle, extending posteriorly to junction of anterior and middle thirds of acromion. Create flat undersurface. EXAM KEY: Goal is to convert Type II/III to Type I (flat) acromion - remove spur but preserve structural integrity.
Surgeon's Tip
EXAM KEY: Goal is to convert Type II/III to Type I (flat) acromion - remove spur but preserve structural integrity.
Danger Zone
- Iatrogenic injury to adjacent structures
8
Smooth Acromial Undersurface: Use rasp or high-speed burr to smooth rough bone edges and create uniform flat surface. Palpate with finger to confirm smooth contour without sharp edges. Irrigate copiously to remove bone debris. EXAM KEY: Rough surfaces cause mechanical irritation - meticulous smoothing prevents postoperative pain.
Surgeon's Tip
EXAM KEY: Rough surfaces cause mechanical irritation - meticulous smoothing prevents postoperative pain.
Danger Zone
- Iatrogenic injury to adjacent structures
9
AC Joint Assessment and Distal Clavicle Excision (if indicated): Palpate AC joint undersurface for osteophytes. If AC arthritis present (preop tenderness, imaging changes, intraop osteophytes), resect distal 1.0-1.5cm clavicle with oscillating saw. Preserve superior and posterior AC ligaments. EXAM KEY: AC joint pathology coexists in 20-30% of cases - address concomitantly to prevent persistent pain.
Surgeon's Tip
EXAM KEY: AC joint pathology coexists in 20-30% of cases - address concomitantly to prevent persistent pain.
Danger Zone
- Iatrogenic injury to adjacent structures
10
Rotator Cuff Inspection and Repair: Systematically inspect rotator cuff from subscapularis (anteriorly) to infraspinatus (posteriorly). Document any tears - location, size, tissue quality, retraction. Perform repair if indicated using suture anchors or transosseous technique. EXAM KEY: 30-40% of patients with impingement have concomitant partial or full-thickness cuff tears - must be addressed.
Surgeon's Tip
EXAM KEY: 30-40% of patients with impingement have concomitant partial or full-thickness cuff tears - must be addressed.
Danger Zone
- Iatrogenic injury to adjacent structures
11
Deltoid Reattachment to Acromion: Drill three 2.0mm transosseous holes through acromion from superior to inferior surface, spaced 1cm apart. Pass #2 non-absorbable sutures (Ethibond, FiberWire) through holes and deltoid periosteum/tendon. Tie securely with arm at side in neutral rotation. EXAM KEY: Secure deltoid repair is CRITICAL - failure causes weakness and poor functional outcome.
Surgeon's Tip
EXAM KEY: Secure deltoid repair is CRITICAL - failure causes weakness and poor functional outcome.
Danger Zone
- Iatrogenic injury to adjacent structures
12
Closure and Dressing: Close deltoid fascia with 2-0 Vicryl interrupted sutures. Close subcutaneous layer with 3-0 Vicryl. Skin closure with 4-0 monocryl subcuticular or staples. Apply sterile dressing and sling for comfort. EXAM KEY: Layered closure reduces dead space and seroma formation.
Surgeon's Tip
EXAM KEY: Layered closure reduces dead space and seroma formation.
Danger Zone
- Iatrogenic injury to adjacent structures
13
ARTHROSCOPIC TECHNIQUE - Patient Positioning: Beach chair (30-45° elevation) OR lateral decubitus position (10-15 pounds traction, 30° abduction, 20° forward flexion). Secure head in holder. Pad all pressure points. Mark bony landmarks: posterior/lateral/anterior acromion, AC joint, coracoid. EXAM KEY: Lateral decubitus provides better glenohumeral joint visualization; beach chair more familiar anatomy and easier conversion to open.
Surgeon's Tip
EXAM KEY: Lateral decubitus provides better glenohumeral joint visualization; beach chair more familiar anatomy and easier conversion to open.
Danger Zone
- Iatrogenic injury to adjacent structures
14
Establish Posterior Portal and GH Joint Inspection: Palpate posterior 'soft spot' (2cm inferior, 2cm medial to posterolateral acromion). Make 1cm vertical incision. Use blunt trocar to enter GH joint. Insert 30° arthroscope. Perform systematic 21-point inspection: biceps, labrum, articular cartilage, rotator cuff undersurface. EXAM KEY: Always inspect GH joint first - may identify pathology requiring arthroscopic treatment (SLAP, Bankart, partial articular-surface cuff tear).
Surgeon's Tip
EXAM KEY: Always inspect GH joint first - may identify pathology requiring arthroscopic treatment (SLAP, Bankart, partial articular-surface cuff tear).
Danger Zone
- Skin necrosis from excessive tension
- Damage to underlying structures
15
Enter Subacromial Space: Withdraw arthroscope to subcutaneous tissue. Redirect to subacromial space - aim trocar beneath acromion, parallel to acromion undersurface. Gently advance until 'give' felt entering space. Inflate space with fluid. EXAM KEY: Gentle technique prevents cuff damage - tight subacromial space in impingement makes entry more difficult.
Surgeon's Tip
EXAM KEY: Gentle technique prevents cuff damage - tight subacromial space in impingement makes entry more difficult.
Danger Zone
- Iatrogenic injury to adjacent structures
16
Establish Lateral and Anterior Working Portals: Lateral portal: Use spinal needle 'outside-in' technique. Place 2-3cm distal to lateral acromion edge in mid-lateral position. Confirm intra-articular with arthroscope visualization. Make 1cm incision and insert cannula. Anterior portal: Via rotator interval, lateral to coracoid. EXAM KEY: Lateral portal is primary working portal - proper placement is critical for efficient bursectomy and acromioplasty.
Surgeon's Tip
EXAM KEY: Lateral portal is primary working portal - proper placement is critical for efficient bursectomy and acromioplasty.
Danger Zone
- Skin necrosis from excessive tension
- Damage to underlying structures
17
Subacromial Bursectomy: Insert arthroscopic shaver through lateral portal. Systematically remove all bursal tissue from medial to lateral, working from AC joint to rotator cuff insertion. Create clear visualization of acromion undersurface, CA ligament, and rotator cuff. Use shaver and radiofrequency device for hemostasis. EXAM KEY: Complete bursectomy is essential for adequate visualization - rushed bursectomy leads to incomplete acromioplasty.
Surgeon's Tip
EXAM KEY: Complete bursectomy is essential for adequate visualization - rushed bursectomy leads to incomplete acromioplasty.
Danger Zone
- Iatrogenic injury to adjacent structures
18
CA Ligament Release: Identify CA ligament origin on anterolateral acromion undersurface. Use arthroscopic electrocautery or radiofrequency device to release ligament from acromion. Control bleeding from acromial artery. EXAM KEY: Complete release required - partial release leads to recurrence. Ligament appears as white, thickened band running from coracoid to acromion.
Surgeon's Tip
EXAM KEY: Complete release required - partial release leads to recurrence.
Danger Zone
- Vascular injury
- Hemorrhage
19
Expose Acromial Undersurface for Acromioplasty: Use shaver and electrocautery to remove all soft tissue from anteroinferior acromion. Expose anterior 2cm of acromion undersurface completely. Identify transition from acromion to clavicle medially. EXAM KEY: Adequate soft tissue clearance is rate-limiting step - bone can't be resected until clearly visualized.
Surgeon's Tip
EXAM KEY: Adequate soft tissue clearance is rate-limiting step - bone can't be resected until clearly visualized.
Danger Zone
- Iatrogenic injury to adjacent structures
20
Arthroscopic Acromioplasty - Bone Resection: Insert arthroscopic burr through lateral portal. Begin resection at lateral acromial edge (just medial to portal site). Remove bone from anterior to posterior, creating flat undersurface. Resect 5-8mm thickness anteriorly, tapering to 2-3mm posteriorly. Extend medially to anterior clavicle border. EXAM KEY: Start laterally where acromion is thinnest, then work medially where it's thicker - prevents premature 'breakthrough' and fracture.
Surgeon's Tip
EXAM KEY: Start laterally where acromion is thinnest, then work medially where it's thicker - prevents premature 'breakthrough' and fracture.
Danger Zone
- Iatrogenic injury to adjacent structures
21
Assess Acromioplasty Adequacy and Smooth Bone: Switch arthroscope to lateral portal to view from working portal position. Assess completeness of resection - should see flat undersurface without anterior hook. Use burr to smooth any rough areas. Palpate acromion undersurface with blunt instrument to confirm smooth surface. EXAM KEY: Viewing from lateral portal provides perspective of humeral head position relative to new acromion undersurface.
Surgeon's Tip
EXAM KEY: Viewing from lateral portal provides perspective of humeral head position relative to new acromion undersurface.
Danger Zone
- Iatrogenic injury to adjacent structures
22
Distal Clavicle Excision (if indicated): If AC joint arthritis present: Use burr to resect 10-15mm of distal clavicle. Work from inferior to superior. Preserve superior AC capsule/ligaments. Create slight oblique cut (anterior less than posterior) to prevent anterior clavicle prominence. EXAM KEY: Arthroscopic DCE can be performed from either subacromial (easier) or intra-articular (direct visualization) approach.
Surgeon's Tip
EXAM KEY: Arthroscopic DCE can be performed from either subacromial (easier) or intra-articular (direct visualization) approach.
Danger Zone
- Iatrogenic injury to adjacent structures
23
Rotator Cuff Inspection and Documentation: Systematically inspect entire cuff from subscapularis to infraspinatus. Document any tears: location (anterior/posterior, articular/bursal), size, retraction, tissue quality. Probe suspicious areas. Address as indicated - debridement for partial, repair for full-thickness. EXAM KEY: Final inspection with clear subacromial space allows accurate cuff assessment - critical for patient counseling and prognosis.
Surgeon's Tip
EXAM KEY: Final inspection with clear subacromial space allows accurate cuff assessment - critical for patient counseling and prognosis.
Danger Zone
- Iatrogenic injury to adjacent structures
24
Final Irrigation and Portal Closure: Irrigate copiously to remove bone debris. Remove all instruments. Close portal sites with 3-0 or 4-0 nylon simple sutures. Apply sterile dressing and sling. EXAM KEY: Thorough irrigation removes debris that could cause synovitis or heterotopic ossification.
Surgeon's Tip
EXAM KEY: Thorough irrigation removes debris that could cause synovitis or heterotopic ossification.
Danger Zone
- Iatrogenic injury to adjacent structures