Abstract
Although the exact function of the subacromial bursa as it relates to rotator cuff repair is still debatable, most surgeons would agree that the more invasive the procedure, the more likely there will be scarring and/or adhesions, which can lead to decreased motion. So, when performing subacromial bursectomy during rotator cuff repair, “Observe due measure, moderation is best in all things [subacromial].”
Although the famous axiom “some is good, more is better” applies to many things in our practices (e.g., vacation time and ancillary clinic help), Nam, Park, Lee, and Kim
1
have shown us, through their article “Outcomes Following Limited or Extensive Bursectomy During Rotator Cuff Repair—Randomized Control Trial,” that extensive bursectomy during arthroscopic rotator cuff repair is not one of them. By performing a randomized prospective, double-blind Level I study with excellent methodology, they have shown that limited bursectomy (debridement of just enough posterior bursa to visualize the subacromial space) leads to statistically significantly better external rotation at 1 year postoperatively and less bursal thickening (which may be interpreted as scarring) at 6 months postoperatively than with extensive bursectomy (resection of the entire bursa). Through strict inclusion criteria and methodology, the authors have minimized variables by having all procedures performed by a single surgeon, excluding procedures with concomitant acromioplasty or SLAP repairs, avoiding regional anesthesia supplementation in all patients, and implementing a standardized postoperative rehabilitation protocol. Although the rate of concomitant biceps tenotomy or tenodesis was slightly higher in the extensive bursectomy group (71% vs 61%, P = .0327), this was not believed to be a significant factor for scarring or decreased motion because subpectoral rather than suprapectoral or in-the-groove tenodeses were performed.The exact function of the subacromial bursa as it relates to rotator cuff repair is still debatable. Some authors have claimed that the bursal tissue is inflamed and pathologic and should be removed,
2
, 3
whereas others have advocated bursectomy to decrease pain by removing the nociceptive pain generators.4
, 5
Yet others have espoused the benefits of retaining the subacromial bursa to provide vascularity and growth factors to the rotator cuff.6
, 7
Regardless of which argument you believe, most surgeons would agree that the more invasive the procedure, the more likely there will be scarring and/or adhesions, which can lead to decreased motion. In the current study, external rotation was, on average, 13° less in the complete bursectomy group than in the limited bursectomy group.1
Given that the minimal clinically important difference for active shoulder external rotation is 3° ± 2° in arthroplasty patients8
and 11° to 14° for passive external rotation (at both 0° and 90°) in healthy versus injured shoulders,9
this loss of external rotation is not only statistically significant (P = .009) but also clinically significant.These results mirror what I see in my practice: The more I do in the subacromial space during a rotator cuff repair procedure (decompression, distal clavicle resection, or bursectomy), the higher the likelihood of early postoperative and even late stiffness. So, for the next rotator cuff repair, let's heed the paraphrased advice of the Greek historian/poet Hesiod, who figured it out nearly 3000 years ago: “Observe due measure, moderation is best in all things [subacromial].”
10
Hesiod. Works and Days. Line 694. Circa 700 bc. https://www.ellopos.net/elpenor/greek-texts/ancient-greece/hesiod/works-days.asp.
Supplementary Data
- ICMJE author disclosure forms
References
- Outcomes after limited or extensive bursectomy during rotator cuff repair: Randomized control trial.Arthroscopy. 2018; 34: 3167-3174
- The role of tendon and subacromial bursa in rotator cuff tear pain: A clinical and histopathological study.Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3779-3786
- The molecular pathophysiology of subacromial bursitis in rotator cuff disease.J Shoulder Elbow Surg. 2005; 14: 84S-89S
- Neurohistology of the subacromial space.Arthroscopy. 1996; 12: 182-186
- Increased substance P in subacromial bursa and shoulder pain in rotator cuff diseases.J Orthop Res. 1998; 16: 618-621
- Surgical repair of rotator cuff ruptures. The importance of the subacromial bursa.J Bone Joint Surg Br. 1991; 73: 399-401
- Blood supply of the subacromial bursa and rotator cuff tendons on the bursal side.Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2041-2046
- Quantifying success after total shoulder arthroplasty: The minimally important clinical difference.J Shoulder Elbow Surg. 2018; 27: 298-305
- Evaluating change in clinical status: Reliability and measures of agreement for the assessment of glenohumeral range of motion.N Am J Sports Phys Ther. 2010; 5: 98-110
Hesiod. Works and Days. Line 694. Circa 700 bc. https://www.ellopos.net/elpenor/greek-texts/ancient-greece/hesiod/works-days.asp.
Article info
Footnotes
The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
See related article on page 3167
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© 2018 by the Arthroscopy Association of North America
