Acromioplasty: Not a one-size-fits-all procedure
Surgeons have performed acromioplasty to reduce pain and prevent rotator cuff disease progression since the 1970s. However, in the past decade, a number of randomized trials have brought the appropriate use of acromioplasty into question.
“There is certainly evidence out there that would suggest routine acromioplasty is not always indicated in subacromial disease patterns and/or with concomitant rotator cuff surgery,” Matthew T. Provencher, MD, CAPT, MC, USNR (Ret.), professor of surgery and orthopedics at Uniformed Services University of the Health Sciences and shoulder, knee and sports surgeon at the Steadman Clinic, told Orthopedics Today. “[W]hether they have been randomized trials or pooled data studies, such as systematic reviews, they have not shown a clinically significant benefit. Although some of them did show improvement in overall outcome scores, the benefit was felt not to be clinically meaningful or significant.” However, there are certainly some cases where acromioplasty is clearly indicated.
Due to this increasing evidence, in 2010, the American Academy of Orthopaedic Surgeons released clinical practice guidelines on the management of rotator cuff injuries that included moderate strength evidence that did not require routine acromioplasty at the time of rotator cuff repair. Updated in 2019, the current clinical practice guidelines provide moderate strength evidence that does not support the routine use of acromioplasty as concomitant treatment for small - to medium-sized full-thickness rotator cuff tears compared with arthroscopic repair alone.
Changed CPT code
In January 2012, CMS also changed the CPT code for arthroscopic acromioplasty (29826) from a stand alone code to an add-on code after performing a 5-year review that revealed arthroscopic acromioplasty was used in combination with codes for shoulder arthroscopy with rotator cuff repair (29827); shoulder arthroscopy with biceps tenodesis (29828); and shoulder arthroscopy with distal claviculectomy (29824) in 97% of cases.
“Medicare has a policy that if you list a CPT code pair over 50% of the time, they can designate the lesser value code as an add-on code. That is what was decided for acromioplasty, 29826, an add-on code,” William R. Beach, MD, past president of the Arthroscopy Association of North America and an Orthopedics Today Editorial Board Member, said. “That means it is not a standalone code. It has to be added on to something and, unfortunately, the reimbursement for it was also decreased.”
Provencher said many considerations should be taken into account when it comes to acromioplasty, which is not a one-size-fits-all procedure.
Identified through a combination of clinical suspicions, it may be difficult for surgeons to come to a specific diagnosis for painful shoulder conditions, such as subacromial impingement syndrome, according to Mark A. Frankle, MD, chief of shoulder and elbow surgery at Florida Orthopaedic Institute.
“There is not one thing that will tell you someone has pain from any of these mechanical conditions ... because it often requires a history that allows you to think that way, and then there are varying tests that you can do on physical exam that give you additional information,” Frankle, president of the American Shoulder and Elbow Surgeons, said.
Surgeons also have two concepts of the acromion to consider during diagnosis: the classic impact of the anterior acromion, classified as type I, type II and type III, and the impact of the lateral acromion and its relation to the critical shoulder angle and rotator cuff pathology, Mark H. Getelman, MD, co-director of the sports medicine fellowship at Southern California Orthopedic Institute/UCLA Health, said.
“We have further complicated our understanding of the acromion in some ways with more knowledge and now you have to make a clinical decision when you are taking care of an individual patient,” he said. “I find it is a challenging decision.”
While patients with shoulder pain and associated large, traumatic rotator cuff tears may undergo acute surgical repair, Getelman, president-elect of the Arthroscopy Association of North America, said surgeons will maximize nonoperative measures in patients with shoulder pain who lack full-thickness rotator cuff tears.
According to Provencher, patients with a relatively intact rotator cuff, pathology in the subacromial space and inflammation may benefit from a comprehensive rehabilitation program that aims to work the rhomboid, serratus anterior, low trapezius and stretch the pectoralis minor.
“A situation of pain in the subacromial space is magnified by a tight pec minor and then also a weak low trapezius, weak serratus anterior, weak rhomboids, and that allows the scapula and then, subsequently, the acromion to tilt anteriorly and rotate internally. So, that even causes additional pressure and constraint in the subacromial space,” Provencher, the Section Editor of Sports Medicine for Orthopedics Today, said. “It is important to address the dynamic muscles around the scapula to keep the subacromial space open and improve the subacromial mechanics through the acromion.”
In addition to physical therapy, it is important to break the pain cycle and help the muscles improve and stretch, Provencher said.
Pain reduction may be achieved through the use of anti-inflammatory medication and corticosteroid injections, according to Getelman.
Indications for acromioplasty
Frankle said patients with recurrent symptoms for 3 months after nonoperative treatment may have a mechanical cause for their pain.
“When we operate on someone who has shoulder pain and we have a tentative diagnosis that there is a mechanical problem, the reason we think that is because the symptoms seem to respond to nonoperative treatment, but they do not seem to be durably improved,” Frankle told Orthopedics Today. “They might get better for weeks, maybe months, and then patients return with recurrent complaints. So, now we think there is a mechanical reason because we were able to get them better, but it did not stay better, and patients often want a more durable outcome,” he said.
With significant pain receptors in the subacromial space, Getelman said it is possible an acromioplasty may help reduce a patient’s pain “by perhaps denervating the undersurface of the bony structure.”
“I do not have a prospective study that says that I can prove that, but I do think there is a component of it,” he said. “If I do not do an acromioplasty and the patient continues to have pain, then I say I should have done an acromioplasty. But, if I do an acromioplasty and the patient still has pain, then I have to look for other sources of it.”
Patients may benefit from an acromioplasty when the acromion has pathology, such as a thickened ligament that contributed to rotator cuff degeneration and bursal irritation, according to Provencher. He said acromioplasty may be beneficial when addressing pathology associated with a diseased subacromial space, including addressing the coracoacromial ligament, a large acquired bone spur on the acromion that can be associated with rotator cuff disease, especially the anterior aspect of the rotator cuff (supraspinatus).
“[Acromioplasty] is not a blanket procedure but we still know, as orthopedic surgeons, that once ... the patient has the issue, we can see it on MRI, we can see it preoperatively, we can see it on radiographs and we can see it under arthroscopic examination, that there are plenty of cases that have a disease pattern that is associated with acromion pathology,” he said.
There may also be times when patients do not have additional pathology, such as rotator cuff tear, associated with a diseased subacromial space, according to Provencher.
“There is certainly a product that we are providing as orthopedic surgeons in the operating room for this patient, of which almost every time they have had nonoperative time, they have had physical therapy, they have had the stabilizer exercise, they have had the stretching of the pec minor [and] they have had the injection which has proven efficacy of pain improvement in the subacromial space,” he said. “It is also proven that this is where their pathology lives and many times, a subacromial debridement and light acromioplasty is what the patient needs to help break their pain cycle and continue the rehabilitation process,” Provencher said.
Despite being a fairly safe operation, John E. (Jed) Kuhn, MD, MS, chief of shoulder surgery at Vanderbilt University Medical Center, said surgeons who perform acromioplasty should not make the acromion too thin. This could lead to stress fractures, as well as potential fractures if reverse shoulder arthroplasty is ever needed. Aggressive acromioplasties may also lead to anterosuperior escape, where the humeral head escapes through the space made when performing acromioplasty, he said.
Among patients with os acromiale, “if you destabilize the anterior bone with an aggressive acromioplasty, that can lead to symptoms in some patients, as well,” Kuhn said.
If performed appropriately, however, acromioplasty can improve visualization for surgeons and can potentially help with healing because it exposes cancellous bone, which is a great source of growth factors and bone marrow elements, Getelman said.
“If you pay careful attention to detail and you do not do [an aggressive acromioplasty], then the risks of humeral escape or other complications related to the acromioplasty are small,” he said.
Flaws in existing studies
Although this is a controversial area, the debate about whether to perform acromioplasty has spurred surgeons to identify patients who would benefit most from the procedure, Beach said.
“For a long time, few rotator cuff repairs were done without an acromioplasty and it probably was overused in those days,” Beach said. “I think one of the benefits of this controversy is it has made us look more critically at when we do acromioplasty and we when we do not.”
Although Frankle said potential methods to ensure surgical metrics and patient outcomes support the use of acromioplasty and may help reduce overutilization, surgeons may still not “get it right every time,” he said.
“There is no, ‘This is clearly impingement. This person, by this imaging study, needs this operation.’ That does not exist,” Frankle said. “That means there needs to be judgment in order to make the correct indication to do the operation and that is harder than it seems because you develop judgment by experience [and] you get experience from bad judgment, typically.”
Existing studies on acromioplasty used in rotator cuff repair and shoulder impingement syndrome procedures also present with significant flaws. “It is not clear whether or not [the patients] have an abrasion,” Frankle said. “You can see that would make it difficult to use the scientific evidence that is currently available to say, ‘I would never do [acromioplasty]. It is not worthwhile.’ When you look in [the shoulder] and you see a clear abrasion and it is rubbing, it seems obvious, at least to me, those patients will benefit.”
Randomized trials, which provide an overview of a population of patients, can also dilute information on the specific patients who may benefit the most from acromioplasty, according to Kuhn, who said the only way to identify the patients who would benefit from an acromioplasty would be to perform a cohort study.
“Even though the randomized trials have been telling us there is not much role for acromioplasty, I think most orthopedic surgeons believe that in certain patients acromioplasty may have some benefit, but the trials, unfortunately, have not been able to tell us who those patients are,” Kuhn said.
Challenging research question
Although ongoing research on acromioplasty would be benefit from having greater numbers of patients involved, since most surgeons always performed acromioplasty in the past, there is not a database with a large enough number of patients who either did and did not receive acromioplasty to compare, Beach said.
However, according to Getelman, prospective studies that compare different groups can be challenging to perform because patients may not select a surgical procedure in which they may end up in the placebo group,
“It becomes challenging for us to get those studies done, with a large enough cohort, that are going to be appropriately powered so we can get the information that we are looking to get,” Getelman said.
Powerful, data pooled across many studies can lead to some erroneous pathways due to researchers feeling “beholden to the studies that have been performed and the methodology behind [them],” Provencher said.
“Once we have an approach and an ability to not do this one-size-fits-all acromioplasty, [except for the patients who] need it, and we are able to study that better, I think we will see significant improvement in our outcomes and the ability to go back to the insurer and say [what works],” Provencher said.
Use acromioplasty when needed
Surgeons who find acromioplasty as a beneficial procedure to have in their armamentarium should continue to follow the literature and be open to new treatment approaches, according to Beach.
Frankle said surgeons should also document patient outcomes and be realistic in assessing how effective acromioplasty is in their hands.
“In fact, those treatments [that] are not as effective, I do not continue to utilize them,” Frankle said. “My utilization of arthroscopic subacromial decompression since I started 30 years ago is substantially less now than it was then, but it is not zero. In my own experience, I still think, in certain patients, it is effective.”
Because can be complicated to identify patients who may benefit from acromioplasty, he said surgeons should communicate their intentions for surgery with patients and what may happen if it turns out the diagnosis is incorrect.
“You have to have this communication with the patient that the reason you are operating could be because of persistent pain and you have this hypothesis of what you think you are going to find during the operation,” Frankle said, noting surgeons also should explain any alternative situations that might arise and cause deviation from the treatment plan.
Although not receiving payment for bonified work has its challenges, Provencher said surgeons should continue to use acromioplasty when it is needed.
“I would encourage surgeons to do what is going to provide, in your hands, the most meaningful and impactful improvement for the patient,” Provencher said. “That may include ... some level of acromioplasty for certain patients, and I would encourage us to do that to ensure we are getting the best patient outcomes.”
However, surgeons also should be aware an acromioplasty will not be needed for every patient and its use should be individualized to each case, according to Getelman.
“Based on the patient’s response to nonoperative management and the evaluation of the radiographs and MRI, you may find there is indication to move forward with acromioplasty, but use your intraoperative visualization of the acromion to make that determination and I recommend that you do more of an anatomic smoothing,” he said.
- Elkousy H, et al. J Bone Joint Surg Am. 2014;doi:10.2106/JBJS.M.01173.
- Management of rotator cuff injuries. Available at: www.orthoguidelines.org/topic?id=1027. Accessed Feb. 9, 2021.
- Paavola M, et al. Br J Sports Med. 2021;doi:10.1136/bjsports-2020-102216.
- Weber S, et al. J Am Acad Orthop Surg. 2020;doi:10.5435/JAAOS-D-19-00463.
- For more information:
- William R. Beach, MD, can be reached at 1501 Maple Ave., Richmond, VA 23226; email: email@example.com.
- Mark A. Frankle, MD, can be reached at 13020 Telecom Pkwy. N., Temple Terrace, FL 33637; email: firstname.lastname@example.org.
- Mark H. Getelman, MD, can be reached at 6815 Noble Ave., Van Nuys, CA 91405; email: email@example.com.
- John E. (Jed) Kuhn, MD, MS, can be reached at 4200 MCE South Tower, 1215 21st Ave. South, Nashville, TN 37232; email: firstname.lastname@example.org.
- Matthew T. Provencher, MD, CAPT, MC, USNR(Ret.), can be reached at 181 West Meadows Dr., Suite 400, Vail, CO 81657; email: email@example.com.