Clinical Sports Medicine Update

Arthroscopic Versus Open M

Acromioplasty
A Meta-Analysis
A. David Davis,* MD, Sanjeev Kakar,* MD, MRCS, Chris Moros,† DO,
‡ §||
Elizabeth Krall Kaye, PhD, MPH, Anthony A. Schepsis,* MD, and Ilya Voloshin, MD
From the *Department of Orthopaedic Surgery, Boston University Medical Center, Boston,
†
Massachusetts, the New York College of Osteopathic Medicine, Old Westbury, New York,
‡
the Goldman School of Dental Medicine, Boston University, Boston, Massachusetts, and the
§
Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York

Background: To address persisting controversy in the literature concerning the efficacy of arthroscopic compared to open
acromioplasty, a meta-analysis was performed to evaluate the treatment effect after both approaches.
Hypothesis: The final clinical outcomes will be the same after both open and arthroscopic acromioplasty. However, the arthro-
scopic technique results in faster recovery and less postoperative morbidity as reflected by faster return to work and decreased
hospital stays.
Study Design: Meta-analysis; Level of evidence, 3.
Methods: We performed our search of published English language literature using PubMed. We also searched the proceedings
from 4 major orthopaedic meetings convened from 2000 to 2007. Furthermore, the reference sections of all relevant articles were
reviewed for pertinent studies and presentations. Nine studies met the inclusion criteria that directly compared arthroscopic ver-
sus open acromioplasty with minimum follow-up of 1 year. The analysis focused on 1-year clinical outcome and included com-
parison of the objective 100-point score, hospital stay, time until return to work, operative time, and complications.
Results: No significant differences were found in clinical outcomes or complications for the 2 groups. However, open acromio-
plasty was associated with longer hospital stays (2.3 days, P = .05) and a greater length in time until return to work (65.1 days)
compared with the arthroscopic technique (48.6 days) (P < .05).
Conclusion: Arthroscopic and open acromioplasty have equivalent ultimate clinical outcomes, operative times, and low compli-
cation rates. However, arthroscopic acromioplasty results in faster return to work and fewer hospital inpatient days compared
with the open technique.
Keywords: shoulder impingement; subacromial impingement; rotator cuff tendinitis; rotator cuff disease; acromioplasty; sub-
acromial decompression

Subacromial impingement syndrome is often cited as the
most common cause of chronic anterior shoulder pain.1,14,16
Impingement syndrome, described extensively by Neer14 in
1972, results from a compression of the rotator cuff
between the anteroinferior edge of the acromion and the
coracoacromial arc during elevation of the shoulder.
||
Address correspondence to Ilya Voloshin, MD, Department of
Orthopaedics, Shoulder and Elbow Service, University of Rochester
Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642
(e-mail: ilya_voloshin@urmc.rochester.edu).
No potential conflict of interest declared.
The American Journal of Sports Medicine, Vol. 38, No. 3
DOI: 10.1177/0363546508328100
© 2010 The Author(s)
From that time, anterior acromioplasty has been an
accepted method of surgical treatment for patients who
have failed conservative therapy.14 An arthroscopic
approach to acromioplasty was then described by Ellman5
in 1987 and has been shown in numerous studies6,9,22,24 to
be an effective alternative to open acromioplasty.
Despite an increasing trend toward arthroscopic decom-
pression, most comparative studies have demonstrated
equivalent outcomes between both treatment modalities.¶
In addition, variable rates of recovery and time until return
to work have been reported, but with no clear consensus
as to which technique is superior. Considerable controversy
in the literature remains as to whether arthroscopic
¶
References 2, 8, 10, 11, 17, 19, 20, 23.

613
614 Davis et al The American Journal of Sports Medicine

acromioplasty leads to a similar or better outcome and TABLE 1

speed of recovery when compared with the open procedure. Studies Included in Meta-Analysisa
The purpose of this study was to perform a systematic
review and meta-analysis of clinical trials within the liter- Number of Patients Mean Follow-up, mo
ature and primarily compare the outcomes of arthroscopic
Study ASD OSD ASD OSD
and open approaches upon follow-up a minimum of 1 year
after surgery. Bezer2 55 90 24 24
Husby8 15 19 96 96
Lazarus10 46 24 24.8 30.6
METHODS Lindh11 10 10 24 24
T’Jonck23 21 15 12 16
Literature Search Sachs19 19 22 13 13
Schroder20 96 80 30 30
We performed our search of the published literature using Spangehl21 32 30 25.1 25.1
MEDLINE/PubMed.13 The search included all indexed Van Holsbeeck24 53 53 20.1 27.3
articles appearing from 1966 to 2007 using the key words a
identifying the population (shoulder impingement, sub- ASD, arthroscopic subacromial decompression; OSD, open
acromial impingement, rotator cuff tendinitis, rotator cuff subacromial decompression.
disease) and the interventions (acromioplasty, subacromial
decompression). In addition, we conducted a manual
a 100-point scale using multiplication factors (Table 2). In
search of the proceedings from 4 major orthopaedic meet-
their analysis, Romeo et al17 compared UCLA, Constant-
ings (American Academy of Orthopaedic Surgeons,
Murley, and Simple Shoulder Test (SST) scores converted to
American Orthopaedic Society for Sports Medicine,
a 100-point scale to find fair correlation among the 3 instru-
Arthroscopy Association of North America, and American
ments and to patient satisfaction in rotator cuff repair.
Shoulder and Elbow Surgeons open annual meetings)
convened from 2000 to 2007. Furthermore, the reference
sections of all relevant articles were reviewed for pertinent Statistical Analysis
studies and presentations that may have been missed
during the computerized search. For each outcome variable (clinical outcomes, complica-
tions, hospital stay, subject satisfaction, and time to
return), the within-study difference between the arthro-
Inclusion Criteria scopic and open acromioplasty groups was computed by
subtracting the mean value of the open group from the
All inclusion and exclusion criteria were established
mean of the arthroscopic group. A positive difference indi-
before the literature search. After review of all the
cated the arthroscopic group scored higher than the open
abstracts identified by the search, we included all studies
group. The mean difference was weighted by the inverse of
that directly compared arthroscopic versus open acromio-
the study variance using methods described by Basu for
plasty techniques for the treatment of subacromial
continuous measures and rate differences.18 The null
impingement syndrome. In addition, any article with a
hypothesis was this weighted difference equal to zero. A
clear selection bias favoring either open or arthroscopic
P value < .05 rejected the null hypothesis.
acromioplasty or comparing only subpopulations of the
2 groups was excluded from our study. Both reviewers
identified the number of eligible studies based on the RESULTS
selection criteria. The agreement between reviewers on
inclusion or exclusion of studies was 100%. Ten studies There were 432 patients in the arthroscopic group and
met the inclusion criteria that directly compared arthro- 343 patients in the open acromioplasty group. The groups
scopic versus open acromioplasty with minimum follow- were similar in demographic characteristics. Out of the 9
up of 1 year. However, a study by Norlin15 included the studies, 7 reported objective clinical outcome scores, such
same patient population as a study by Lindh and Norlin,11 as the UCLA shoulder score, Constant-Murley scoring
and was therefore excluded. The 9 studies were included scale, and the PSS score. Six of the 9 studies reported
in the meta-analysis (Table 1). hospital stays, 5 reported time it took to return to work
and complications, and 4 of the 9 reported operative times
Data Extraction (Table 2). Lindh and Norlin11 kept both groups of patients
for 2 days postoperatively as part of the protocol. For this
Data collected from the selected studies included demo- reason it was excluded for comparison of the differences in
graphics, surgical technique, clinical outcomes, hospital hospital days between the 2 techniques. No significant dif-
stays, operative time, time until return to work, and all ferences were found in clinical outcomes, patient satisfac-
reported complications. A common data set was created for tion, or complications (Table 3). Because the UCLA
the clinical outcomes for the meta-analysis. University of shoulder score was the most commonly used objective clin-
California at Los Angeles (UCLA), Constant, and Penn ical outcome scoring system, we performed a separate
Shoulder Score (PSS) scores were each normalized to analysis of all those studies using this system. Consistent
Vol. 38, No. 3, 2010 Arthroscopic Versus Open Acromioplasty 615

TABLE 2
Arthroscopic and Open Decompression Data Analysisa

Number Subject Operative Hospital Return to Outcome 100-Point

Study Technique of Patients Satisfaction, % Time, min Stay, d Work, d Scores Scale Complication

Spangehl21 ASD 32 87.5 No data No data No data 28.8 (UCLA) 82.3 0

Spangehl21 OSD 30 93.3 No data No data No data 28.1 (UCLA) 80.3 0
Lindh11 ASD 10 No data 40 2 No data 29 (UCLA) 82.9 No data
Lindh11 OSD 10 No data 66 2 No data 29 (UCLA) 82.9 No data
Van Holsbeeck24 ASD 53 88.3 No data 0 63 31.1 (UCLA) 88.9 No data
Van Holsbeeck24 OSD 53 94.3 No data 4.5 81.2 31.3 (UCLA) 89.4 No data
Sachs19 ASD 19 90 No data 0 36 No data No data 0
Sachs19 OSD 22 95 No data 1.6 54 No data No data 1 infection
Husby8 ASD 15 90 82 No data 39.9 32 (UCLA) 91.4 No data
Husby8 OSD 19 90 50 No data 70 32 (UCLA) 91.4 No data
Bezer2 ASD 55 89.6 No data 1.36 9 83.1 (Const) 83.1 0
Bezer2 OSD 90 95.4 No data 1.72 16 80.5 (Const) 80.5 0
Schroder20 ASD 96 82 38 1.3 No data No data No data 0
Schroder20 OSD 80 68 55 5.5 No data No data No data 2 infections,
1 hematoma
10
Lazarus ASD 46 76.7 75.7 1.8 95.2 81.2 (PSS) 81.2 0
Lazarus10 OSD 24 87.5 75.8 2.3 104.3 82.4 (PSS) 82.4 0
T’Jonck23 ASD 21 No data No data No data No data 80.8 (Const) 80.8 No data
T’Jonck23 OSD 15 No data No data No data No data 73.8 (Const) 73.8 No data
a
ASD, arthroscopic subacromial decompression; UCLA, University of California at Los Angeles shoulder score; OSD, open subacromial
decompression; Const, Constant Score; PSS, Penn Shoulder Score.

TABLE 3
Results of Meta-Analysis of Difference in 100-Point Score, Patient Satisfaction,
and Complication Rate of Open and Arthroscopic Acromioplasty Treatment Studiesa

100-Point Score Patient Satisfaction Rate, % Complication Rate, %

Difference Study Weight, % Difference Study Weight, % Difference Study Weight, %

Spangehl 2.0 36.3 –5.8 10.0 0.0 12.6

Lindh 0.0 1.3
Van Holsbeeck –0.5 5.1 –6.0 19.6
Sachs –5.0 8.6 –5.0 8.3
Husby 0.0 1.1 0.0 7.3
Bezer 2.6 6.0 –5.8 30.5 0.0 29.4
Schroder 13.6 –4.0 35.6
Lazarus –1.2 49.3 14.0 5.7 0.0 14.2
T’Jonck 7.0 1.0 –10.8
Summary mean difference 0.34 –3.0 –1.0
(95% confidence interval) (–0.86, 1.54) (–7.7, 1.7) (–4.0, 3.0)
a
Outcome difference (arthroscopic minus open).

TABLE 4 with our results found via the Meta score, there was no
Results of Meta-Analysis of Difference in UCLA Scorea significant difference in the UCLA scores between the
open and arthroscopic approach (Table 4). Open acromio-
UCLA Score
plasty, however, was associated with longer operative
Difference Study Weight, % time, hospital stays, and time to return to work (Table 5).
The mean difference in hospital stay (Figure 1) was calcu-
Spangehl 0.7 83.0 lated to be 2.3 days (P < .05). Open acromioplasty was
Lindh 0.0 2.9 associated with statistically significant longer operating
Van Holsbeeck –0.2 11.6 times (2.2 minutes; P < .05), a finding, however, that was
Husby 0.0 2.5
deemed to be clinically unimportant. Lastly, the open
Summary mean difference 0.56
approach was found to have a greater length in time to
(95% confidence interval) (–0.08, 1.19)
return to work (65.1 days) compared with the arthroscopic
a
Outcome difference (arthroscopic minus open). technique (48.6 days) (P < .05) (Figure 2).
616 Davis et al The American Journal of Sports Medicine

TABLE 5
Results of Meta-Analysis of Difference in Hospital Stay, Return to Work
and OR Time of Open and Arthroscopic Acromioplasty Treatment Studiesa

Return to Work, d OR Time, min

Hospital Stay, d
Study Study
Difference Study Weight, % Difference Weight, % Difference Weight, %

Spangehl
Lindh –26.0 8.6
Van Holsbeeck –4.5 35.8 –18.2 22.1
Sachs –1.6 12.8 –18 8.5
Husby –30.1 7.0 32.0 6.1
Bezer –0.4 20.3 –7 59.6
Schroder –4.2 6.1 –17.0 10.9
Lazarus –0.5 24.9 –9.1 2.8 –0.1 74.3
T’Jonck
Summary mean difference –2.3 –12.1 –2.2
(95% confidence interval) (–2.5, –2.0) (–13.9, –10.3) (–3.8, –0.6)
a
Outcome difference (arthroscopic minus open). OR, operating room.

3.5 70
3 60
2.5 50 Arthoscopic
2 Arthroscopic 40
Open
1.5 Open 30
1 20
0.5 10
0 0
Mean Hospital Stay Time Until Return to Work

Figure 1. Hospital inpatient days spent by patients treated Figure 2. Time until return to work for patients treated by 2
by 2 subacromial decompression techniques. subacromial decompression techniques.

DISCUSSION
Since Neer first introduced anterior acromioplasty for the
treatment of subacromial impingement, there have been
numerous attempts to modify his approach. The use of a
high-speed bur in place of an osteotome, retrospectively
studied by McShane et al,12 was found to result in fewer
complications. Additionally, many of the modifications to
Neer’s approach have centered on decreasing morbidity to
the deltoid origin. In the open approach, ideally only 1 cm
of anterior deltoid is taken down from the acromion to
facilitate an appropriate exposure.24 McShane et al12
reported superior outcomes with the use of a deltoid split,
thereby avoiding having to take down the anterior deltoid
from the acromion. This approach avoids the complications
of deltoid morbidity and pain at the repair site.
With improved surgical technique and instrumentation,
arthroscopic acromioplasty has become technically possible
for an ever-increasing number of orthopaedic surgeons. The
allure of performing arthroscopic acromioplasty stems from
the belief that performing the procedure with smaller inci-
sions leads to less soft tissue disruption, resulting in
decreased postoperative pain and morbidity.2,10,14 Despite the
challenges of this technique, the outcomes of arthroscopic
acromioplasty have been successful and compare favorably
with results obtained with the open technique.2,8,10,11,19,21-24
One of the major theoretical advantages of arthroscopic
acromioplasty includes the deltoid sparing technique,6
which leaves the deltoid insertion mostly untouched.
Because the arthroscopic approach obviates deltoid repair,
range of motion exercises can be initiated in the immediate
postoperative period. This avoids the delay in rehabilitation
that is seen in patients requiring protection of a deltoid
repair performed as a consequence of an open acromioplasty.
In addition, the arthroscopic approach has also gained wide-
spread appeal as a result of its superior cosmesis.
In a few comparatively small clinical trials, clinically valid
outcomes may lack statistical significance because the study
was underpowered. Oftentimes, important outcomes cannot
be viewed as generalized trends due to the lack of statistical
Vol. 38, No. 3, 2010
significance. This becomes important in areas of medicine
where obtaining a large sample size is cost-prohibitive and
logistically difficult. This can be illustrated when evaluating
literature that compares arthroscopic versus open acromio-
plasty. Nine published studies have demonstrated contra-
dicting results for these 2 surgical approaches to subacromial
impingement. Although potentially significant differences
were found in many of the studies, they were not reported as
statistically significant because of the low number of
patients enrolled in each study.
The meta-analysis combines data from multiple studies,
generates adequate sample size, and determines statisti-
cally significant differences in outcomes based on the
effects of an intervention.4
This study has important limitations. The ultimate qual-
ity of a meta-analysis depends on the quality of the pri-
mary studies on which it is based, and it is most
persuasive when the data from these high-quality ran-
domized trials are pooled together.3,7 In this meta-analysis,
there were 4 level-1, 1 level-2, and 4 level-3 studies. As
Bhandari et al3 acknowledged, meta-analyses that pool
data from nonrandomized or observational trials are sub-
ject to all of the limitations of the primary studies; the
inferences from this study may be limited accordingly. The
limitations inherent in meta-analyses emphasize the need
for conducting quality, randomized, controlled clinical trials
to answer important questions in the field of orthopaedic
surgery. Yet the literature concedes that in the absence of
large, quality, randomized clinical trials, meta-analysis
of smaller studies is the best source of information for
evidence-based practice.7
We performed a meta-analysis to determine if there were
any differences between the 2 techniques not only in clini-
cal outcomes, but also in socioeconomic factors such as
length of stay in the hospital and duration of time it took to
return to work. In addition to clinical outcomes, socioeco-
nomic factors are also important determinants in estab-
lishing the efficacy of a surgical approach. Despite the
challenge of extracting and interpreting data from the pri-
mary studies, the evidence has shown that arthroscopic
acromioplasty and open acromioplasty result in similar
final clinical outcomes; however, arthroscopic acromio-
plasty is associated with a decrease in inpatient stay by
almost 2 days (Figure 1) and a return to work more than 2
weeks sooner than patients treated by an open acromio-
plasty (Figure 2).
CONCLUSION
Arthroscopic and open acromioplasty have equivalent ulti-
mate clinical outcomes, operative times, and low complica-
tion rates. However, arthroscopic acromioplasty results in
faster return to work and fewer hospital inpatient days
compared to the open technique.
ACKNOWLEDGMENT
The authors thank Kimberly A Napoli for assistance in
preparing this manuscript.
Arthroscopic Versus Open Acromioplasty 617
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