Near-Normal Shoulder Function 10 Years After Complete Acromionectomy: A Case Report

Jeffrey F. Rasmussen; David W. Wing; Mark E. Steiner

摘要

In 2010, Vitale et al~( 11 )demonstrated the rising rate of acromioplasties being performed in New York State, which increased from 5571 in 1996 to 19,743 in 2006. Despite the high rate of acromioplasties currently performed, the precise role of the acromion remains incompletely understood. With intimate attachment to the deltoid, the acromion provides a lever arm for strength in shoulder abduction.~( 8 )However, numerous reports have implicated the acromion in the development of shoulder pain from impingement and rotator cuff tears.~( 1 , 2 , 5 ) Reginald Watson-Jones reported the first acromial excision in 1939 for the treatment of supraspinatus tendon lesions at a meeting of the British Orthopaedic Association.~( 1 )In 1949, Armstrong~( 1 )reported a series of 95 patients with supraspinatus syndrome thought to be the result of abnormal compression of the rotator cuff tendons and subacromial bursa between the humeral head and acromion. All patients underwent complete excision of the acromion to the acromioclavicular joint, with 84.2% (80/95) showing satisfactory results.~( 1 )In 1962, Hammond~( 5 )reported good-excellent outcomes in 85.7% (18/21) of patients after complete acromionectomy for the diagnosis of supraspinatus syndrome/tendinitis. In 1991, Bosley~( 2 )described 34 shoulders treated with total acromionectomy for chronic impingement syndrome. At a minimum 2-year follow-up, 85.3% (29/34) of shoulders had good-excellent function in terms of pain, strength, range of motion (ROM), and patient satisfaction.~( 2 ) Despite initially promising results, complete/radical acromionectomy is subject to poor outcomes in some patients. In 1981, Neer and Marberry~( 9 )reported a series of 30 consecutive patients who had poor results after complete acromionectomy. They identified 8 patients with serious wound complications, 27 with persistent pain, and all 30 exhibiting marked shoulder weakness with an inability to raise the arm above 90°. They advocated for partial excision of the anterior one-third of the acromion with release of the coracoacromial ligament to prevent impingement.~( 9 )Jeon et al~( 6 )reported on 10 patients requiring deltoid/acromion reconstruction after failed acromionectomy. All patients complained of disabling persistent symptoms, all exhibited deltoid muscle retraction with cosmetic deformities, and none of the patients could actively raise the arm above 90°.~( 6 ) We present the clinical history and outcomes of a 26-year-old man who underwent complete acromionectomy at the age of 16 years for pain secondary to an aneurysmal bone cyst (ABC). The findings demonstrate that the absence of the acromion may not significantly impair function, provided the deltoid is intact. Case Report At 16 years of age, an otherwise healthy male patient presented to an outside clinic with persistent pain in the right shoulder. Historical data of that time period were obtained from a complete review of the patient’s medical records, including office notes, imaging reports, operative report, and pathology report. Initial radiographs revealed a well-circumscribed, expansile, lytic lesion of the acromion consistent with an ABC, and surgical excision was elected. From the operative report of the outside surgeon, it was noted that the deltoid and trapezius were released from the acromion, complete acromionectomy was performed, and the deltoid and trapezius were directly repaired to one another. A pathological evaluation confirmed the diagnosis of an ABC. At 6 months, the patient was seen in routine postoperative follow-up and was noted to have excellent strength in his deltoid, supraspinatus, infraspinatus, teres minor, and subscapularis muscles, with no perceivable deficit compared with the contralateral side. At 10-year follow-up, the patient underwent a formal examination to evaluate and document the function of this acromionectomy-treated shoulder. His unaffected contralateral side served as the control. The patient was examined using standardized ROM assessments, including active and passive elevation and abduction as well as active internal and external rotation at 90° and 0° of abduction. Clinical evaluations of the scapular position both at rest and with overhead motion were performed ( Figure 1 ). Functional outcomes were measured using the American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and Western Ontario Rotator Cuff Index (WORC). Strength testing, both isometric and isotonic, was performed using a work simulator (BTE). For isometric testing, torque was measured for internal and external rotation, forward elevation, and abduction from a position with the elbow at the side. The patient was asked to perform maximum effort for 3 seconds, with a 10-second break between each trial. The average of the 3 trials was reported, and the percentage deficit compared with the contralateral normal shoulder was calculated. For isotonic testing, torque was set

机译：在2010年，Vitale等人（11）证明了纽约州进行的肩峰成形术的比率上升，从1996年的5571增加到2006年的19,743。尽管目前进行的肩峰成形术的比率很高，但肩峰成形术的确切作用仍然存在不完全了解。肩峰与三角肌紧密相连，提供了杠杆臂，可增强肩外展的力量。〜（8）然而，许多报道都表明肩峰撞击和肩袖撕裂引起肩部疼痛。〜（1，，2， 5）雷金纳德·沃森-琼斯（Reginald Watson-Jones）于1939年在英国骨科协会的一次会议上报告了第一例行肩峰切除术，以治疗脊柱上肌腱损伤。〜（1）1949年，阿姆斯特朗（（1））报告了95例脊柱上肌综合征患者被认为是肱骨头和肩峰之间肩袖肌腱和肩峰下方滑囊异常受压的结果。所有患者均接受了肩峰完全切除手术，其中84.2％（80/95）疗效满意。〜（1）1962年，Hammond〜（5）报告良好的结果为85.7％（18/21）。肩峰切除术后患者的诊断为棘上综合征/肌腱炎。 1991年，Bosley〜（2）描述了34例肩部全肩峰切除术治疗慢性撞击综合征。在至少2年的随访中，有85.3％（29/34）的肩膀在疼痛，力量，运动范围（ROM）和患者满意度方面具有出色的功能。〜（2）尽管最初结果令人满意，部分患者行彻底/根治性肩峰切除术的预后较差。 1981年，Neer和Marberry〜（9）报告了30例连续的患者，他们在完成肩峰切除术后均表现差。他们确定了8例严重伤口并发症，27例持续疼痛，全部30例表现出明显的肩膀无力且无法将手臂抬高90°以上的患者。他们主张部分切除前三分之一的肩峰，并释放冠状韧带以防止撞击。[9] Jeon等人[6]报告了10例在肩峰切除术失败后需要三角肌/血栓重建的患者。所有患者均抱怨禁用了持续性症状，均表现出三角肌回缩并伴有畸形畸形，并且所有患者均无法主动将手臂抬高至90°以上。〜（6）我们介绍了一名26岁男性的临床病史和预后由于动脉瘤性骨囊肿（ABC）继发的疼痛，在16岁时接受了全顶肢切除术。这些发现表明，如果三角肌完好无损，则没有肩峰可能不会明显损害其功能。病例报告16岁时，一名其他情况健康的男性患者因右肩持续疼痛来到一家外部诊所就诊。该时间段的历史数据来自对患者病历的完整检查，包括办公室记录，影像报告，手术报告和病理报告。最初的X线照片显示与ABC相符的肩峰的边界清楚，可扩张，溶解性病变，并选择了手术切除。从外科医生的手术报告中，注意到三角肌和斜方肌从肩峰被释放，进行了完整的肩峰切除术，并且三角肌和斜方肌直接彼此修复。病理评估证实了ABC的诊断。在第6个月时，患者接受了常规的术后随访，发现其三角肌，脊上肌，蛛网下肌，小畸形肌和肩cap下肌具有出色的力量，与对侧相比，没有明显的缺陷。在10年的随访中，该患者接受了正式检查，以评估并记录经肩峰切除术治疗的肩膀的功能。他未受影响的对侧为对照。使用标准的ROM评估对患者进行了检查，包括主动和被动抬高和外展，以及在外展90°和0°时的主动内外旋转。对肩rest骨在静止和俯卧时的位置进行了临床评估（图1）。使用美国肩肘外科医师（ASES）评分，手臂，肩部和手部残疾（DASH）评分以及西安大略肩袖旋转指数（WORC）来测量功能结局。等强度和等渗强度测试是使用工作模拟器（BTE）进行的。对于等距测试，从肘部在侧面的位置测量了内部和外部旋转，向前抬高以及外展的扭矩。要求患者尽最大努力3秒钟，每次试验间隔10秒钟。报道了三项试验的平均值，并计算了与对侧正常肩相比的缺损百分比。对于等渗测试，设置扭矩

Near-Normal Shoulder Function 10 Years After Complete Acromionectomy: A Case Report

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