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    r IG . 2A fter ex cis ion o f the acrom ion four and a half y ea rs P reV i0lI5 lY

    the ho ne has re fo rm ed a lm ost com ple tely .

    a b aFIG. 4

    b

    EX C IS ION O F TH E ACROM ION IN TREA TM ENT OF TH E SU PRA SPINA TUS S \N I)lW M E 43 7

    VO L . 31 B , so . 3 , AUGUST 1949

    T o en su re succes sfu l re su lts a co nsid erab le am oun t o f bon e m ust 1 )e rem oved . Th ispo in t w as no t at first ap prec ia ted an d in the first n in e cases in th is se ries n o t eno ugh of th eacrom ion w as exc ise ti ; in a ttem pting to prese rve th e acrom io-c lav icu lar a rticu la tion th ebone w as d iv itled imm ed ia te ly la te ra l to the jo in t (F ig . 3 ). A t o pera tio n there appeared tobe adequa te c lea rance bu t th e resu lts w ere u nsa tisfac to ry in five o f these pa tien ts. T heupper end o f the hum erus lie s s ligh tly an te rio r to , ra th er th an imm edia te ly be low , the

    FIG . 3Excis ion o f b one d ista l to th e a crom io -clav icu larjo in t (F ig . 3 a) is not alw ay s satis fac tory . It isbe tter to rem ove the acrom io n com ple tel(F ig . 3b) b ecause otherw ise new bon e m aform in the at tachm en t of the de lto id to

    the raw hone surfa ce.

    F ig . 4a is a tra cing of the lin e o f fIrstex cis ion o f the acrom ion in th e ca se show nin F ig . 2 . N ew bone th at fo rm ed w ith ina few months (F ig . 4 b) n ece ssita ted a secon dope ration for com p lete exc isio n at th e

    jo in t lev el.

    acrom ion pro cess and the inse rtion of the suprasp ina tus tendon com es in to con tac t w ith th ean ter io r pa rt o f the p rocess on sh ou ld er m ovem en t. In fact C odm an su ggested th at it w asco n tac t w ith th e co raco -acrom ial lig am en t rath er th an w ith bo ne tha t cau sed th e J )res su re.In any even t it is es sen tial tha t the an te r io r pa rt o f the ac rom ion shou ld be rem ov edcom p lete ly and an y a ttem pt to p re se rv e th e ac rom io -c lav icu lar jo in t m ay cause u nsa tisfac to ryresu lts. M oreov er, w hen the acron iion has been d iv id ed an d the de tached d e lto id m uscle issu tu red to its cu t edge , new bon e fo rm atio n tak es p lace rap id ly and sym ptom s m ay recur(F ig s. 2 -4 ). If the w hole o f the acrom ion process la teral to the acrom io-c lav icu la r jo in t is

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    FIG. 5

    Photo graph of patien t fo ur m on th s a f ter com p lete exc is ion of the rig ht acrom ion (F ig . 5 )and radiograph of the righ t sh oulde r (F ig . 6) and th e left sho ulde r (F ig . 7 ). T he diffe rence

    in co ntou r of the should er is sca rcely notic eable .

    43 8 J. R . A RM ST RO NG

    THE JOURNAL OF BONE AND JOINT SURGERY

    rem oved , th e en d o f the c lav ic le cons titu tes the n ew attachm en t to w hich th e de lto id issu tu red , so tha t f l() raw bone is ex posed in the area in w hich new bone fo rm ation w ould beharmfu l .

    C om ple te exc is io n of the acrom ion does no t app ear to cause un tow ard ef fects . If thecono id an d trapezo id ligam en ts a re un dam aged , loss o f th e acrom io-c lav icu la r jo in t is n o tassoc ia ted w ith any d isab ility . T he cu t edg e of the d e lto id m usc le, su tu red firm ly to thecoraco-ac rom ia l ligam en ts , fo rm s a firm fib rous sca r w hich g ives sup port to th e ou te r en d ofth e clav ic le . Th e o pe ra tion d oes no t re su lt in an y se rio us cosm e tic b lem ish . The sca r is o fcourse v isib le an ti m ay tend to s tretch a little , bu t th e a lte ra tio n of con to ur is no t n o ticeab le(F igs. 5 an d 6). T he po ste rio r ang le o f the cu t ed ge of bo ne shou ld b e round ed off So tha t nosp ike is left.

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    EXC IS ION OF THE ACROM ION IN TREATM EN T OF THE SUPRA SP INA TU S SYN DROM E 43 9

    IND ICAT IONS FOR EXC ISION OF THE ACROM IONB ro ad ly speak ing , exc ision of th e acrom ion is ind ica ted in treatm en t o f the suprasp ina tus

    synd rom e w henever conserva tive trea tm en t has fa iled . M ore prec ise ind ica tions varsaccord in g to ind iv idua l op in ion and they d epend upon a num ber of c ircum stances. T he m ostim portan t s ing le fac to r is the du ra tion of sym ptom s. L esio ns o f the su prasp ina tus g rou pten d to re so lv e and su bside w ith tim e , and op era tion is never a m atte r o f u rgency . Ind eedsom e surg eo ns m ain ta in tha t a ll these lesions recover spon tan eo usly ov er a period of one ortw o yea rs ; bu t ev en if th is w ere tru e , w h ich is to be d oub ted , few p atien ts are p rep ared toto le ra te sym ptom s fo r so long a tim e , n o r is it rea so nab le to expec t them to do so . O n theo the r hand it is im poss ib le to te ll in the ea rly stag es w h ich pa tien t w ill reco ve r an d w hichw ill req u ire op era tion . C on serva tive treatm en t shou ld a lw ay s b e tried fo r a t lea st tw o m onths;and on ly if th e re is no im prov em en t a t the en d of tha t tim e sh ou ld ope ratio n be cons ide red .

    \\hen , as is o ften the case , sym ptom s im p rove to som e ex ten t w ithou t b ein g com ple te lyre lieved , o th er fac to rs m u st d ete rm ine w heth er o r no t op era tion sho u ld be adv ised . Th eseverity o f the sym ptom s and the d eg ree o f assoc ia ted d isab ility a re o bv ious ly im por tan t.In its in itia l stages the acu te syn drom e m ay be acu te ly pa in fu l an d cripp ling , bu t th is ph asedoes no t o f ten pers ist. T h e typ ica l syndrom e is ne ithe r v ery pa in fu l no r com ple telyincapacita ting and its e ffec ts o ften depend on the age , occupa tion an d m ode of life o f th epa tien t. A p ain fu l a rc o f m ov em en t m ay be no m o re than a m ild nu is an ce to an e lde rlypa tien t o f s ed en tary hab its and ye t b e a seve re h an d icap to a y ounge r pe rson w hoseoccupa tio ns a re strenuo us. D iscom fort, a ccep ted ph ilo sop h ically by one w ith a ph legm a tictem peram en t, m ay be devas ta ting in its e ffec ts on a m ore h igh ly strung pa tien t. E achpa tien t w ho does no t respond to conserva tive trea tm en t p rov ides an ind iv idu al p ro b lem ;and the su rg eo ns a ttitud e to op era tion w ill ce rta in ly be in fluen ced pro fo und ly b y h is o p in ionof its e fficacy .

    There are tw o c ircum stances in w h ich ex cisio n of the ac rom ion is co n tra- ind ica ted . \V h enthere is true lim ita tio n of shou ld er m ovem ent, o pera tion p rodu ces a stiff and s tu bborn jo in tw h ich requ ires m onths of trea tm en t befo re m obility is resto red . M usc le sp asm can be d is tin -gu ished from adhesion fo rm ation by exam in a tion afte r th e lesion has b een in f iltra ted w ithloca l an aes the tic o r, be tter s till, by exam ina tion under a g en eral anaes th e tic . I f the re is truelim ita tio n th is m ust b e dea lt w ith by active ex ercises, an d perhaps m an ipu la tion , be fo reopera tion is co n tem p la ted . O pera tion is a lso con tra -ind ica ted if the re is d oub t as to th ed iag nos is . R em ova l o f the aG rom ion w ill re liev e p ressu re on the su prasp in atus ten don orsub acrom ia l bursa bu t if app lied in a h ap hazard m anner to the trea tm en t o f a ll stiff p ain fu lsho u lders th e o pera tio n g iv es very unsa tis facto ry resu lts , pa rticu la rly in pa tien ts vithperiarthritis.

    RESULTSIn 1939 , W atson-Jones first repo rted exc ision of th e acrom ion in th e trea tm en t o f

    suprasp ina tus tend on les io ns a t a m ee ting o f the B ritish O rth opaed ic A ssoc ia tion inO sw estry ; a nd he desc ribed th e pro ced ure in 1943 . A t abou t tha t tim e th is w rite r w as b ecom ingin creas ing ly d issa tis fied w ith the resu lts o f conserva tiv e trea tm en t in m any serv ice pa tien tsw ho w ere und er trea tm en t a t the R oya l A ir Force H osp ital, R au ceb y . T ho se w ho w ere no tp rom ptly re lieved by co nserv ative trea tm en t w ere o ften incapac ita ted fo r lon g periods an dthere seem ed no th ing e lse to offer . A fte r trial o f exc ision of the acrom ion the resu lts w ereencourag in g , p articu la rly w hen ex perien ce h ad sh ow n tha t it w as n ecessa ry to exc ise th e w holeof the acrom ion . C onv ic tion tha t the opera tion w as a good one w as s tren g thened by persona lexperience . In 1944 , a fte r severa l m on th s o f ty p ica l incap acity w hich had pers isted unchang edd esp ite a ll fo rm s of co nserv ative trea tm en t, m y ow n acrom ion p rocess w as ex cis ed by S irR eg in ald W atso n-Jones w ith com ple te and perm anen t cu re . T he resu lts in a persona l se riesVOL . 31 B , so . 3 . AUGUST 1949

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    440 J. R . AR MSTR ON Gof n ine ty -five pa tien ts a re summ arised in T ab le I. B ecause m any of these pa tien ts w erere fe rred fo r o pera tion afte r co nserv ative trea tm en t e lsew here had fa iled , it is no t possib le tosta te the propo rtio n th a t they represen t o f a ll pa tien ts su ffe ring from the suprasp ina tussyndrome.

    In e igh ty of n in ety - five pa tien ts th e opera tio n w as com ple te ly successfu l ; they w erere lieved of sym p tom s and reg a in ed a fu ll range of pow erfu l shou lder m ovem ent. In the f ir stn ine opera tions the acrom ion w as d iv ided fa r enough la te ra lly to prese rve the acrom io-c lav icu lar jo in t. F ive o f th ese pa tien ts g a ined in com ple te relie f o r n on e at a ll. In th reepa tien ts fu rthe r exc is ion of bone gave g ood resu lts . Tw o re-exc is ions w ere carr ied ou t abo u ttw o m onths a fte r the orig ina l opera tio n ; the th ird pa tien t g a in ed in itia l re lief from the firs topera tio n bu t sym ptom s then recurred and a t the tim e of re -exc is io n sev en m on th s la te r newbon e fo rm a tion w as obv iou s. In th e o the r tw o unsu ccessfu l cases pe rm issio n fo r fu r the rop eration w as re fused ; one p atien t w as sa tisfied w ith th e incom ple te re lief he hadga in ed ; the o ther w as d isco uraged by the unchang ed pers istence of h is o rig ina l sym ptom s.In six in stances th e resu lt o f op eration w as unsa tis fac to ry because there w as pos t-o pera tiv e

    TA BLE IRESULTS O F OPERAT ION

    R ESU LTS O F EXC IS ION OF THE AcRo IoN IN N IN ETY -FIV E IAT I ENTSSU FFER ING FROM THE SUPRASPIN ATU S GROU P OF LES IONS

    Satis fac tory to patien t and su rg eon 80 (84 .2 p er cent.)

    Unsa t is f a c tory 15 (15 .8 per cent.)

    ANALYS IS O F FIFTEEN UN SAT I SFACTORY R ESU LTS

    5In su ff icient bo ne rem oved (In three pa tien ts a furthe r

    ex cis ion w as su cce ssfu l)

    Post-o pera tive lim ita tion o f m ovem ent 6

    N o r elie f o f sym p tom s 4

    lim ita tion o f shou lder m ovem ent ; the re w as com ple te relie f o f pa in bu t the range of fo rw ardflex ion and abduc tio n m ovem ent w as reduced by ab ou t on e-th ird an d the pa tien ts , be ingco n ten t w ith relie f o f pa in , w ere u nw illin g to be stim u la ted in m ak ing th e endeavou r n eed edto rega in a no rm a l ran ge o f m ov em en t. F our p atien ts sa id tha t they h ad ga ined n o relie f a ta ll : in tw o th e o rig ina l d iagno sis m ay h ave been inaccu ra te ; and in th e o ther tw o fa ilu re o fthe opera tion is s till un ex p lain ed .

    PATHOLOGICAL F INDING S AT O PERAT IONThe subacrom ia l bursa w as o pened a t op eration in every case an d th e pa th o log ica l

    find in gs w ere no ted . T h e various cond itions th at w ere seen w ere no t a lw ays d is tin c tive lyd iffe ren t, on e from the o the r. N eve rth e le ss it seem ed possib le to c la ssify them in to fou rgro ups (T ab le II).

    F if ty -six pa tien ts appeared to have ten d in itis w ith an assoc ia ted b urs itis. Th e ten donw as red , th ickened and rough ; an d the bu rsa l w a lls and syn ov ia l lin in g w ere o ed em a tous

    THE JOURNAL OF BONE AND JO IN T SU RGERY

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    EXC IS ION OF TH E ACROM ION IN TREA TM ENT OF THE SUPRA SP INA TU S SY NDROME 44 1

    and in f lam ed , these chan ges be ing m o st m ark ed arou nd th e tendon . In recen t an d acu tecases the sy nov ia l m em bran e h ung in red , oedem ato us fo lds. T he ch an ges sug gested tha ttend in itis w as the p rim ary le sion and bursitis secon da ry .

    In ten pa tien ts the prim ary les ion ap peared to be sub acrom ia l bursitis. T he w alls o f thebu rsa w ere red , th ickened and adhe ren t to the ac rom ion ; the cav ity co n ta in ed free flu id an d ,in a few instances , sm all lo ose bo d ies . T h e changes w ere un ifo rm , and no t in an y w ay lo ca lisedto the reg ion of the su prasp in atu s tendon , and th ey w ere exactly sim ila r to those o f ach ron ica lly in flam ed prep ate lla r o r o lec ran on bursa.

    In f ifte en cases ca lc ified depos its in the su prasp ina tus ten don w ere v isib le in the p re -o pe ra tive rad iog raph s. A t op era tion the tendon ap pea red ro ugh , th ickened , op aq ue ands ligh tly red , and there w as ev idence of loca lised burs itis . N o a ttem pt w as m ade to rem ovethe depos its from the tendon .

    T ears o f th e supra sp in atu s tend on w ere foun d in fou rteen pa tien ts . M o st frequen tlythe ten don w as incom ple tely de tached from its inse rtion . T he area of de tachm ent w as sm alland no t assoc ia ted w ith retrac tion such as occurs a fter com ple te ru p tu re . O ccasion ally sm allren ts w ere o bse rv ed in the ten don itself th roug h w hich th e a rticu la r car tilage o f the hum era lhead co u ld be seen .

    TA BLE IIIA THOLOG IC A L FIND ING S

    PA THOLOG IC A L F IND INGS IN N IN ETY -F IV E PAT IEN TS W ITH TH ESUPRASPIN ATUS SY NDROM E

    Tendin itis w ith seconda ry subacrom ial 5 6bursitis

    P rim ary sub ac rom ial burs itis 10

    C alc ific ation in su pra sp in atu s te nd on 15

    Tears or de tachm ents of su pra sp inatus 14tendon

    OPERAT IVE TECHN IQUE AND PO ST -OPERATIVE M ANAGEM ENT

    Certa in po in ts in the techn iqu e , w hich m ake the op eration easie r, a re w orthy of no te .T he pa tien t is la id o n the sound s id e w ith the head w ell flex ed . T he su rgeon sits a t th e topof the tab le , the a rm being con tro lled by an assis tan t. T he inc ision beg ins in f ron t o f theacrom io-c lav icu la r jo in t and ex ten ds back acro ss the jo in t and acrom ion in a d irec tion sligh tlycon cave ou tw ards . A flap of sk in and subcu taneous tis su e is th en ra ised , expos ing the up persu rface of the acrom ion and jo in t. T he perios teum is d iv ided abou t h alf an inch la te ra l tothe p ro posed lin e o f sec tion and re flected inw ard . Th e ac rom io n is d iv ided from befo rebackw ards w ith a sharp osteo tom e he ld very ob liqu ely to av o id the possib ility o f dam age tounde rly ing stru ctu re s. T he line o f sec tion shou ld ex ten d d irec tly backw ards from theac rom io -c lav icu la r jo in t. W hen th e acrom ion has b een d iv ided it is he ld in lion fo rcep s w hilethe de lto id orig in is d etached from its ou te r edg e, w o rk ing from beh ind fo rw ard s. T h esub ac rom ia l b u rsa is u sua lly fou nd to b e adh eren t and m ust be d iss ec ted from the d eepsu rface o f the bo ne . Th e la st s tru ctu re s to be d iv ided a re the acrom io -c lav icu la r and co raco -acrom ial ligam en ts .VOL . 31 B , so . 3 , AUGUST 1949

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    J. R . A RM ST RO NG

    THE JOURNAL OF BONE AND JO INT SU RGERY

    A fte r rem ova l o f the acrom ion the bursa is open ed fo r exam ina tion , and the und erly in gten don is inspec ted , th e arm being abduc ted and ro ta ted as n ecessa ry . T h e bursa l w a ll isc lo sed . T he cu t ed ge of the de lto id is su tu red firm ly to the acrom io -c lav icu la r ligam en ts andre flec ted perios teum or, if n ecessa ry , to the bone itse lf th rough ho les d rilled w ith an aw l.T h e de lto id is repa ired w hile the lim b is he ld in abd uc tion and security o f the su tu re -line isthen tested by low er in g th e arm to the side . T h e sk in is su tu red and a pressu re bandageapp l ied .

    D uring opera tion som e g en eralised arte rio la r b leed ing occurs , bu t no la rge vesse ls a reencoun tered and few lig atu res a re n ecessa ry . It is v ery m uch eas ie r and qu ick er to rem ovethe acrom io n in th is re tro g rad e m anne r than to a ttem pt to c lear its m usc le a ttachm en ts andth en to tliv ide the b one . Th e acrom ion shou ld a lw ays b e cu t clean ly w ith a sharp osteo tomeand never be n ibb led aw ay p iecem ea l.P ost-o pera tive m anagem en t-A fte r op era tion it is u nnecessa ry to imm obilise the lim b inab duc tion . T he pa tien t w ea rs a sling bu t is encou raged to u se th e fo rea rm and hand as m uchas poss ib le . Passive m ovem ents o f the shou lder a re perm itted , the a rm bein g p laced in them o st com for tab le pos itio n or rested on a p illow . T he pa tien t n eed be co nfined to bed on lyfo r four o r five days. A c tiv e m ovem ents o f the sh ou lder a re no t a ttem pted fo r ten days afte ro pera tio n d uring w hich tim e con trac tion of the de lto id is pa in fu l ; bu t a fte r th is in te rva lg en tle sh ou lder exerc ises sh ou ld be encourag ed , p articu la r a tten tio n be ing pa id to ab duc tio n .In the early stages exerc ises a re bes t to le ra ted in the su p ine po sitio n w h ich m in im ises theeffec ts o f g rav ity , and it is adv isab le to con tinue abduc tion ex ercises in th is pos itio n u n tila fu ll rang e h as been rega ined .

    There is o f co urse m uch va ria tion in the ra te o f recove ry o f d iffe ren t pa tien ts . A n activ em an m ay p lay g o lf w itho u t d iff icu lty w ith in fou r w eeks o f ope ratio n ; bu t m ost pa tien ts needsix to e igh t w eek s be fo re they a re ab le to use th e shou lde r w ith con fid en ce. Th e las t tend egrees o f ab duc tion and fo rw ard flex io n m ovem ent a re rega ined slow ly , an d very d)ften ,since the pa tien t m ay no t apprec ia te tha t the re is s till som e lim ita tion of m ov em en t, it isd if ficu lt to persuade h im to persis t ass iduous ly w ith the necessa ry exerc ises.

    A cu te sym ptom s are at once re lieved by the opera tion bu t o f ten there is s lig h t ach ing ,espec ia lly a t n igh t, fo r severa l m onths . Th e cure m ay be reg arded as com plete w hen thepa tien t has no t on ly rega ined a fu ll range o f m ov em en t b u t is a lso ab le to sleep com fortab lya t n igh t on the affected lim b .

    CONCLUS IONS1 . T he supra sp in atu s g ro up o f les ions con stitu tes o ne o f the tw o comm on causes o f thepam fu l sh ou lder.2 . M o st, b u t no t a ll, o f these lesions reso lve e ithe r sp on taneous ly or a fte r conserva tivet reatmen t .3 . \\hen con se rv ativ e trea tm en t fa ils sym ptom s can b e re lieved b y exc is ion o f the acrom io nproce ss , pro v ided tha t su ffic ien t bone is rem oved to re lieve a ll p ressu re on th e tendonth rou ghou t a fu ll ran ge of sho u lde r m ovem en t.4 . Ex cis ion of the acrom io n is con tra -ind ica ted if the re is doub t as to the d iagn osis o r ifthe re is true lim ita tion o f shou lder m ovem ent.

    REFERENCES\ \ATSON- JONES , H . ( 1939 ) : E xc isio n of acrom ion for suprasp ina tus te nd in it is . D em on stra tio n of casesat m eeting o f B r itish O rth opaed ic A sso cia tion , O sw estry .WATSON - JONES , I I. ( 1943 ) : Fracture sand Join t In ju ries . T hirded ition . 418 . Ed inb urg h : E . & S . L iv ings ton e,Ltd .