Mark K. Bowen and Angelo DiFelice

1. Radiographically documented impingement that has failed nonsurgical management (rest, local modalities, nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and judicious subacromial cortisone injections)

2. Full-thickness rotator cuff tears—not repairable

3. Partial-thickness rotator cuff tears—less than 50% thickness of tendon

1. Neuropathic joint

2. Active soft tissue or glenohumeral infection

3. Failed prior surgical treatment with associated deltoid insufficiency

4. Degenerative glenohumeral arthritis (relative); consider combining acromioplasty with shoulder arthroplasty

5. Patient’s overall medical condition (relative)

6. Patient unable to comply with postoperative rehabilitation (relative)

1. Physical examination should include assessment of acromioclavicular (AC) joint tenderness and/or pain with shoulder adduction.

2. Obtain radiographs

a. Anteroposterior (AP) in plane of scapula (“true AP”)

b. AP shoulder (check distal clavicle for “spurs”)

c. Axillary view (check for os acromiale, glenohumeral arthritis)

d. Supraspinatus outlet view (assess acromion shape [types I–III], spinoacromial angle)

e. Twenty-five degree caudal tilt (“Rockwood view”) (optional)

3. Consider magnetic resonance imaging (MRI): Helps evaluate extent (“full” versus “partial” thickness) of rotator cuff tears, and presence of muscle atrophy or tendon retraction; observe mass effect of acromion and AC joint on supraspinatus tendon (impingement).

1. Small sagittal or oscillating saw for bone resection

2. 1.6-mm drill bit for deltoid reattachment

3. Small, half-circle curved free Mayo needle, and #2 braided nonabsorbable suture

4. 5-mm round burr and broad flap rasp to “fine-tune” acromioplasty

6. The head may be secured gently with a padded strap or tape across a pad on the forehead. Care must be taken to avoid the strap or tape from sliding down over the eyes.

7. The procedure can be done with either general or interscalene block anesthesia.

1. Prior to initiating surgery use a marking pen to outline prominent anatomic landmarks. Identification of the acromion, scapular spine, and clavicle is critical for accurate arthroscopic portal and skin incision placement.

2. Consider arthroscopic evaluation of the gleno-humeral joint including the articular surfaces, glenohumeral ligaments, biceps tendon, and the undersurface of the rotator cuff for completeness. Threading an absorbable suture through a spinal needle placed through the torn area can mark partial-thickness tears.

3. Arthroscopic evaluation of the subacromial space may reveal near complete full-thickness rotator cuff tears in the setting of an apparent intact cuff on intra-articular examination.