SUBACROMIAL DECOMPRESSION - dnbid

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SUBACROMIAL DECOMPRESSION:

SUBACROMIAL DECOMPRESSION DR. D. N. BID The Sarvajanik College of Physiotherapy, Surat, India

INDICATIONS:

INDICATIONS Impingement syndrome Painful arc When conservative management have failed Than Anterior Acromioplasty is indicated in patients who have irreparable rotator cuff tears.

INVESTIGATIONS:

INVESTIGATIONS History taking Examination > impingement tests Plain X-ray > sclerosis on the undersurface of acromian and osteophytes formation on the ant edge of acromian. > in advance impingement : the distance between the acromian and humeral head is narrowed less than 7 mm. Ultrasonography MRI

Technique :

Technique Beach chair position A superior strap incision is made over the lat border of acromian, exposing the ant edge of the acromian and the junction of the ant third and post two thirds of the deltoid muscle. This muscle is than split in the line of its fibers, detaching the deltoid from the ant portion of the acromian. This exposes the coraco-acromial ligament , which is released from the front edge of the acromian.

CONTINUED…:

CONTINUED… The anterior edge of the acromian is then excised and any osteophytes or ‘beaking’ of the acromian removed. Bigliani has described three shapes of acromian; types I- III. It is probable that the increased beaking of the acromian is acquired rather than congenital. Once acromioplasty has been undertaken the rotator cuff can be inspected from its sup surface. Often a glenohumeral arthroscopy will have been undertaken, before an open acromioplasty, to allow inspection of the bursa from the joint surface.

CONTINUED…:

CONTINUED… It is possible that a rotator cuff tear may be found at the time of surgery and this may then be repaired. The deltoid is closed with interrupted sutures. The muscle can usually be reattached to the periosteum of the acromian, bur sometimes bone sutures are required to allow a stable and secure repair. The wound is then closed often infiltrated with local anesthetic. A sling is then placed over the arm

Anesthetic :

Anesthetic General and regional anesthesia combination

Post operative management:

Post operative management Immediately after surgery patient should be instructed in maintenance exercises to the neck, shoulder, elbow and wrist. Early passive movements of the shoulder also commenced. Patients are advised to use the sling for net 24-48 hours, then to remove it for short periods, as comfort permits. Driving after 1-2 weeks. Manual labor after 4 weeks.

Complications :

Complications Infection Pain and stiffness

Arthroscopic Subacromial Decompression:

Arthroscopic Subacromial Decompression Same incision but smaller in size as in open acromioplasty Rather than making an open incision through the deltoid, the coraco-acromial ligament is released from within the bursa and the ant edge of the acromian removed using arthroscopic burrs; the advantage being reduced post op morbidity. The wounds are much smaller and heal more quickly.

CONTINUED…:

CONTINUED… Manual work can usually be resumed after 4-6 weeks and driving between 1 and 2 weeks. Arthroscopic subacromial decompression does not appear to confer any advantage over open decompression at six months.

Physiotherapy following subacromial decompression (without rotator cuff repair):

Physiotherapy following subacromial decompression (without rotator cuff repair) Post operatively, the shoulder is often swollen, the swelling being worse if the surgery was lengthy . A padded dressing is applied over the arthroscopy site and the shoulder rested in a sling. Movement will initially be limited by swelling. The arm may be very painful immediately postoperatively and the rehab of these patients is often hindered by insufficient analgesic cover. Patients must be encouraged to take their analgesics before PT. Ice may be applied immediately after surgery to control pain and swelling.

CONTINUED…:

CONTINUED… Pendular swinging exercises are commenced on the first post op day in the same manner as those described for shoulder arthroplasty; these are frequently painful. When pain allows, usually between 24-48 hours, active assisted exercises may commence using a pulley system to increase elevation, although care must be taken as this can increase impingement. The sling will be discarded as soon as possible, usually at about 1 week. Mobilizing exercises are continued from 48 hours, most patients attaining flexion and abduction to 90 degree by 2 weeks post-operatively.

CONTINUED…:

CONTINUED… Out patient PT usually commences once inflammation has settled . Full ROM may be acquired on an out-patient basis using the same technique as described for total shoulder arthroplasty. This is followed by strengthening exercises, concentrating on internal and ext rotation.

CONTINUED…:

CONTINUED… Final rehab allowing diagonal movement patterns may be attained by using either Bad Ragaz technique in the hydrotherapy pool or PNF tech. The pain associated with rehab will be variable but may be considerable. Most improvements in pain occur in the first three months post-operatively but often pain will continue for up to a year.

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