Bursectomy and Acromioplasty

The shoulder bursa is a fluid-filled sac that lubricates the plane of motion of tissues on top and below the bursa.  An analogy is the motor oil in a car engine.  The tissues in the front and on top of the bursa (acromion, coracoacromial ligament, coracoid, deltoid) need to move freely and without friction from the underlying rotator cuff and biceps tendons.  If there is too much friction, when an acromion spur is pinching down, or when the rotator cuff or biceps are inflamed, bursitis results, which contributes to pain.  Bursitis, or inflammation of the bursa, is corrected with a procedure called a bursectomy (where a motorized instrument called a shaver) sucks the inflamed bursa out of the shoulder.  Bursectomy not only helps the surgeon visualize the underlying tendon of the rotator cuff and biceps but can improve pain.  Typically bursectomy is performed in conjunction with an acromioplasty to ensure the bursitis does not come back.

Acrmioplasty is technically a re-shaping of the roof bone (acromion) of the shoulder so that it no longer causes impingement, tearing, and inflammation of the underlying bursa and rotator cuff.  There are two contributory factors within the acromion anatomy that contribute to problems of the rotator cuff (called rotator cuff disease).  First is the individual anatomy of the patient, which is variable depending on how curved or hooked the acromion is.  Bigliani first described three different appearances of the acromion in 1986 and noted that more “hooked” acromion anatomy was, the more likely it was the patient was also experiencing a rotator cuff tear(1).  The second contributory factor within acromion anatomy related to rotator cuff disease is spur formation at the acromion, which occurs as a chronic process where the ligament attached to the acromion (called the coracoacromial ligament) pulls on the acromion over years and causes a spur to form where the ligament attaches on the acromion.  Both hooked appearance of the acromion and spurs contribute to rotator cuff disease and it is for this reason that re-shaping of the acromion alone can be successful for rotator cuff disease without tears, including for conditions such as tendinopathy and tendonitis.  Acromioplaty is performed as a minimally invasive procedure with a camera (scope), where a tiny powered instrument called a burr, is introduced to gently re-shape the acromion.

The majority of rotator cuff repairs are performed in conjunction with acromioplasty for several reasons, most notably as to prevent the pinching or compression/impingement lesion that led to the tear in the first place.  By re-shaping the acromion (also called a subacromial decompression), the spurs are removed, the acromion is flattened, effectively making space below for the repaired tendon of the rotator cuff.  While some surgeons have different preferences about when to perform an acromioplasty in the setting of arthroscopic rotator cuff repair, not performing an acromioplasty can sometimes lead to greater failure rates after the tendon is repaired, causing a higher rate of reoperation(2).  Other potential benefits of acromioplasty include the exposure of the inner bone surface of the acromion, which bleeds and may emanate elements that improve tendon healing, including stem cells and growth factors.

Generally surgical decompression of the acromion is used when other nonsurgical measures for impingement syndrome have failed, including home exercises, supervised therapy, activity modification, and corticosteroid injections.  Acromioplasty should be considered as a last resort, and when used is considered definitive and predictable, although there is a recovery process and some risks associated with the procedure.

When these procedures are performed in isolation (and no tendon repairs are performed), the surgery is relatively quick, you leave the facility the same day, and start exercises within several days.  The sling is removed once comfort allows in a week or two and by three weeks you may resume full activities to tolerance.  Most patients are very happy with results by six to eight weeks, where they are comfortably sleeping through the night and resuming recreation such as golf.  It is important to know that it can take up to a full year for all of the soreness to completely be eliminated from the shoulder.