Systematic Review With Video Illustration The Role of Subacromial Decompression in Patients Undergoing Arthroscopic Repair of Full-Thickness Tears of the Rotator Cuff: A Systematic Review and Meta-analysis Jaskarndip Chahal, M.D., F.R.C.S.C., Nathan Mall, M.D., Peter B. MacDonald, M.D., F.R.C.S.C., Geoffrey Van Thiel, M.D., M.B.A., Brian J. Cole, M.D., M.B.A., Anthony A. Romeo, M.D., and Nikhil N. Verma, M.D. Purpose: The purpose of this study was to determine the efficacy of arthroscopic repair of full-thickness rotator cuff tears with and without subacromial decompression. Methods: We searched the Cochrane Central Register of Controlled Trials (third quarter of 2011), Medline (1948 to week 1 of September 2011), and Embase (1980 to week 37 of 2011) for eligible randomized controlled trials. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed by use of a random effects and relative risk model with computation of 95% confidence intervals. Results: We included 4 randomized trials and 373 patients. Methodologic quality was variable as assessed by the CLEAR NPT (Checklist to Evaluate a Report of a Non-pharmacological Trial) tool. One trial showed that there was no difference in disease-specific quality of life (Western Ontario Rotator Cuff questionnaire) between the 2 treatment groups. A meta-analysis of shoulder-specific outcome measures (American Shoulder and Elbow Surgeons or Constant scores) or the rate of reoperation between patients treated with subacromial decompression and those treated without it also showed no statistically significant differences. 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. ince originally described by Neer in 1972,1 acro- Smioplasties have become 1 of the most commonly performed procedures in orthopaedic surgery.2 They are usually performed as part of a formal subacromial From the Division of Sports Medicine, Rush University Medical decompression (SAD), which involves an anteroinfe- Center (J.C., N.M., G.V.T., B.J.C., A.A.R., N.N.V.), Chicago, Illi- rior acromioplasty, coracoacromial ligament release, nois, U.S.A.; and Pan Am Clinic, Division of Orthopaedic Surgery, and subacromial bursectomy. In a population study by Department of Surgery, University of Manitoba (P.B.M.), Winni- peg, Manitoba, Canada. Vitale et al.,2 the volume of acromioplasties (isolated The authors report that they have no conflicts of interest in the and combined with other procedures) in New York authorship and publication of this article. Received October 16, 2011; accepted November 16, 2011. State increased by 254.4% over an 11-year period Address correspondence to Jaskarndip Chahal, M.D., F.R.S.C.S., (1996 to 2006). Similarly, the mean number of 555 W Kinzie St, Chicago, IL 60654, U.S.A. E-mail: jaschahal@ arthroscopic acromioplasties increased by 142.3% hotmail.com © 2012 by the Arthroscopy Association of North America among candidates eligible for part 2 of their orthopae- 0749-8063/11675/$36.00 dic surgery board certification examination over a doi:10.1016/j.arthro.2011.11.022 10-year period (1999 to 2008). The most common Note: To access the video accompanying this report, visit the May indication for an SAD remains subacromial impinge- issue of Arthroscopy at www.arthroscopyjournal.org. ment with or without a concomitant rotator cuff tear. 720 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 5 (May), 2012: pp 720-727 META-ANALYSIS OF SAD FOR RCR 721 The rationale for performing an acromioplasty in published in the literature that has addressed this con- the setting of rotator cuff repair (RCR) is historically troversy. The objective of this systematic review was anchored to the theory of extrinsic subacromial im- to identify and summarize the available Level I evi- pingement, which has been popularized by Neer1 and dence to compare the efficacy of performing acromio- Bigliani et al.3 This theory is grounded on the princi- plasty in patients undergoing repair of full-thickness ple that acromial morphology is the initiating factor tears of the rotator cuff. We hypothesized that there leading to dysfunction of the rotator cuff and eventual would be no difference in outcome among patients tearing.4 The influence of this theory on the practice of who did receive an acromioplasty and those who did shoulder surgery has been profound because several not during arthroscopic repair of full-thickness rotator authors have advocated that acromioplasty is an inte- cuff tears. gral part of RCR.5-8 However, proponents of the in- trinsic theory of rotator cuff failure purport that ab- normalities of the rotator cuff occur when eccentric METHODS tensile overload occurs at a rate greater than the ability Inclusion Criteria of the cuff to repair itself.4 According to the intrinsic theory, acromioplasty fails to address the primary Types of Studies and Interventions problem of intratendinous degeneration or tendinosis. Potential benefits of acromioplasty include improved Randomized or quasi-randomized controlled trials visualization for arthroscopic technique, as well as that compared the role of SAD versus no SAD in access to bleeding in the subacromial space, which patients undergoing repair of full-thickness rotator may improve healing potential. Potential disadvan- cuff tears were included. Minimum 1-year follow-up tages of routine SAD include violation of the soft- was also required for inclusion. Our preferred tech- tissue envelope during arthroscopy leading to intraop- nique of arthroscopic double-row RCR is illustrated in erative soft-tissue swelling, weakening of the deltoid Video 1 (available at www.arthroscopyjournal.org). origin by detachment of some of its anterior fibers, Types of Participants anterosuperior instability in the presence of a failed rotator cuff or irreparable tear, and the formation of Participants were patients aged older than 18 years adhesions between the raw exposed bone on the un- who were diagnosed with a full-thickness tear of at dersurface of the acromion and the underlying tendon, least 1 rotator cuff tendon. which in turn can limit smoothness, motion, comfort, and range of motion.9 There is also uncertainty as to Outcomes whether acromioplasty can prevent the progression of The primary outcome of interest was disease- rotator cuff failure.9 specific quality of life as measured by the Western On the basis of the framework proposed by the Ontario Rotator Cuff (WORC) index (continuous vari- intrinsic theory of rotator cuff degeneration, several able). Secondary outcomes of interest (when avail- investigators have challenged whether SAD needs to able) included (1) shoulder joint–specific patient-re- be performed concomitantly with rotator cuff surgery. ported outcome measures including Disabilities of the Budoff et al.4 reported good and excellent results in Arm, Shoulder and Hand questionnaire,11,12 Univer- 81% of cases at long-term follow-up (minimum of 5 sity of California, Los Angeles outcome score,13 Con- years) in patients undergoing debridement alone for stant-Murley outcome score,14 Pennsylvania Shoulder partial-thickness rotator cuff tears without simultane- Score,15 American Shoulder and Elbow Surgeons ous SAD. Matsen and colleagues10 also reported sig- (ASES) outcome score,16 Simple Shoulder Test,17 nificant improvements in health-related quality of life L’Insalata scoring system,18 visual analog scale and Simple Shoulder Test scores in 96 consecutive (VAS) for pain; (2) postoperative range of motion; repairs of full-thickness tears of the rotator cuff with- and (3) rate of reoperation. out SAD. Both of the aforementioned studies did not have a control group, and hence direct comparisons Search Strategy could not be made. At this time, there is ongoing debate as to whether We used a text-search strategy using the terms acromioplasty results in improved outcomes in pa- “(subacromial decompression OR acromioplasty) tients undergoing repair of full-thickness rotator cuff AND rotator cuff” under the limit “randomized con- tears. To our knowledge, there is no systematic review trolled trials.” Specifically, we searched the Cochrane 722 J. CHAHAL ET AL. Central Register of Controlled Trials (third quarter of intervals (CIs) were calculated for all point estimates. 2011), Medline (1948 to week 1 of September 2011), The I2 statistic19 was used to quantify heterogeneity, Embase (1980 to week 37 of 2011), and www.clini- whereas the Cochran ␹2 test of homogeneity (i.e., Q caltrials.gov for completed and ongoing randomized test, P Ͻ .10) was used to test for heterogeneity. controlled trials. We also assessed the bibliographies Data from eligible studies were pooled by use of a of identified studies to seek additional articles. We did random effects model because of the anticipated het- not restrict our search or inclusion by language. Meet- erogeneity among study populations, surgical treat- ing archives and abstract proceedings were searched ment protocols, and differences in lengths of immo- from the American Association of Orthopedic Sur- bilization and physical therapy. Heterogeneity was geons and American Orthopaedic Society for Sports planned to be explored by subgroup analysis of re- Medicine from 2009 to 2011. In the event where a trial sults (age, gender, Workers’ Compensation, acromion was published in abstract form only, the study authors type). A sensitivity analysis was used by removing 1 were contacted for access to a complete study manu- study at a time from the pooled analysis for recurrent script. The final list of eligible studies was reviewed shoulder instability to test the robustness of our re- with content experts to ensure that there were no sults. missing trials. Study Selection RESULTS The primary author parsed through all citations and General Study Characteristics abstracts generated by the literature search and applied The results of the search, the study selection log, selection criteria with a tendency toward inclusion.