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OS ACROMIALE

Christian Dumontier, MD, PhD


Centre de la Main, Guadeloupe, FWI
HISTORICAL REVIEW

• 1st description, in 1863 by


Gruber.

Gruber W. Über die Arten der Acromialknochen und accidentellen Acromialgelenke. Arch Anat Physiol Und wissensch Med.
1863:373–378.
EMBRYOLOGY
• Development of acromion proceeds
from many nuclei

• Nuclei consolidate during


adolescence forming three separate
ossification centers

• Pre-acromion (Coracoacromial lgt


and anterior deltoid)

• Meso-acromion (middle deltoid)

• Meta-acromion (posterior deltoid)

• Basi-acromion From Spriegl, UJ


EMBRYOLOGY

• The three centers


consolidate to form the
acromion

• Age of consolidation varies


between 14 years of age (at
least 1/3 are already
consolidated) to 25 years of
age.
EPIDEMIOLOGY
• Os acromiale is a failure of ossification
between two of the apophyses

• Prevalence may vary according to races

• 11,1-20% of African-americans

• 0,7% in Koreans

• 1,9-15% in caucasians

• More frequent in males

• Bilateral involvement in 30 to 62% of cases

• Most frequently between meso and meta-


acromion
EPIDEMIOLOGY

From Spriegl, UJ
THEORIES
• Mechanical

✤ High frequency in archers of XV and XVIth


centuries

✤ Correlation with number of throw in javelin


throwers

• Genetic
Roedl JB, Morrison WB, Ciccotti MG, Zoga AC. Acromial apophysiolysis: superior shoulder pain and acromial nonfusion in the
young throwing athlete. Radiology. 2015;274(1):201-209.
Stirland A. Patterns of trauma in a unique medieval parish cemetery. Int J Osteoarchaeol. 1996;6:92-100.
THEORIES
• Mechanical

• Genetic:

• 8% of os acromiale in cadavers, 33% being


bilateral

• Distribution varies according to races

Sammarco VJ. Os acromiale: frequency, anatomy, and clinical implications. J Bone Joint Surg Am. 2000;82(3):394-400.
CLINICAL PRESENTATION
• Asymptomatic +++

• Age of diagnostic in symptomatic individuals vary


from adolescence to 70 years of age

• Atraumatic origins mostly

• After minor or repetitive trauma


CLINICAL PRESENTATION
• Tenderness over the acromion

• Limitation of anterior elevation (< 120° in all Warner’s patients)

• Impingement signs (Neer, Hawkins,..) are common

• Diminished shoulder strength

• AC joint is normal +++

• Local injection may relieve pain


Warner JJ, Beim GM, Higgins L. The treatment of symptomatic os acromiale. J Bone Joint Surg Am. 1998;80(9):1320–1326.
IMAGING

• Plain X-rays: usually visible


on the axillary view
IMAGING

• Double-density sign on the


AP view and supraspinatus
outlet view has been
reported to be sensitive (82
and 94%) and specific (95
and 100%).
From Lebus, GF

Lee DH, Lee KH, Lopez-Ben R, Bradley EL. The double-density sign: a radiographic finding suggestive of an os acromiale. J Bone
Joint Surg Am. 2004;86-A(12):2666–2670
CT-SCAN
IMAGING

• MRI > CT Scan to rule out


associated pathologies

• MRI > CT scan to show


sclerotic and cystic changes,
increased signal in acromion
and surrounding tissues
indicative of a mobile
pseudarthrosis

From Uri, DS
TREATMENT OF SYMPTOMATIC OS
ACROMIALE

• Non operative management: avoid trauma,


corticosteroid injections, rehabilitation, others,..

• Surgical: excision (open-A°), acromioplasty, ORIF


w/wo bone graft.

• In 56% of cases, rotator cuff repair was performed


at the same time (Purnell)
ARTHROSCOPIC EXCISION
• Case series

• 11 pts, (18-25 yrs), meso-acromial type with excellent results


(Pagnani)

• 12 pts, meso-acromial type, 92% satisfactory (Wright)

• 28 pts, meso-type, 20 painless, 9 diminished, 2 (6%) worse


(Campbell)

Pagnani MJ, Mathis CE, Solman CG. Painful os acromiale (or unfused acromial apophysis) in athletes. J Shoulder Elbow Surg.
2006;15(4): 432–435.
Wright RW, Heller MA, Quick DC, Buss DD. Arthroscopic decompression for impingement syndrome secondary to an unstable
os acromiale. Arthroscopy. 2000;16(6):595–599.
Campbell PT, Nizlan NM, Skirving AP. Arthroscopic excision of os acromiale: effects on deltoid function and strength. Orthopedics.
2012;35(11):e1601–1605.
OPEN RESECTION

• With deltoid attachment

• Good results (Boehm),

• Only good results in pre-type, poor results in meso-type


(Warner)

Warner JJ, Beim GM, Higgins L. The treatment of symptomatic os acromiale. J Bone Joint Surg Am. 1998;80(9):1320–1326.
Boehm TD, Matzer M, Brazda D, Gohlke FE. Os acromiale associated with tear of the rotator cuff treated operatively. Review of
33 patients. J Bone Joint Surg Br. 2003;85(4):545–549.
ACROMIOPLASTY

• Two series found no difference with ORIF in meso-type os


acromiale

• Only 8% of published cases

Boehm TD, Matzer M, Brazda D, Gohlke FE. Os acromiale associated with tear of the rotator cuff treated operatively. Review of
33 patients. J Bone Joint Surg Br. 2003;85(4):545–549.
Abboud JA, Silverberg D, Pepe M, et al. Surgical treatment of os acro- miale with and without associated rotator cuff tears. J
Shoulder Elbow Surg. 2006;15(3):265–270.
ORIF
• Cannulated screws may
improve healing rate compare
to K-wires and diminish
hardware removal

• Cannulated screws with tension


band is more rigid and may cannulated screws with tension band (from Spiegl)
improve failure rate

• Clinical results are correlated


with bone healing

• 57% of published cases


COMPARAISON OF SURGICAL TECHNIQUES ?

• Systematic review

• 19 studies , 210 patients, 221 shoulders

• 46 years (19 to 78)

• 65% of male

• 4% pre-acromion, 94% meso acromion, 3% meta-acromion

• All patients improved regardless of the technique used

• 87 complications reported (including asymptomatic hardware removal)


SURGICAL COMPLICATIONS

• Non union rates vary between 0 and 100% !

• Deep infection in 13% and superficial infection in 6% of


cases (Boehm)

• Hardware removal
REFERENCES
• Spiegl UJ et al. Optimal management of symptomatic os
acromiale: current perspectives. Ortho Research and reviews
2018;10:1-7.

• Lebus GF et al. Operative Treatment of Symptomatic Meso-Type


Os Acromiale. Arthroscopy techniques 2017;6(4):1093-1099.

• Purnell JA et al. Clinical results and complications following


surgical management of symptomatic os acromiale: a systematic
review. J of Ortho Surg and Reseach 2019;14(26)