10- Dr. Amol Tambe_AJA.cdr

Shoulder complaints are common; with lifetime prevalence ranging from 6.7–66.7% [1]. Approximately 70% is related to rotator cuff pathology [2]. The incidence of rotator cuff tear (RCT) is approximately 70% of those aged 70 years or above; with 40% having a ‘massive’ rotator cuff tear (involvement of two or more tendons) [3]. Many are asymptomatic, but frequently it can reduce quality of life years due to pain and impaired function. Symptomatic RCTs present a significant societal and economic burden; particularly with an aging population and increased labour force participation of the elderly [4]. Markov decision model cost-effectiveness analysis suggests operative treatment of RCTs results in lifetime age-weighted mean total societal saving of $13,771 (US) per patient [4]. An acute tear is typically seen following shoulder dislocations or trauma in younger patients [3]. However, theories regarding chronic RCT formation pertain to intrinsic and extrinsic factors. The intrinsic theory, as proposed by Codman [5], describes tendon degeneration occurring within a zone of hypo-vascularity; typically located 10 mm from its insertion. Poor regenerative properties, eccentric tensile loading and repetitive micro-instability result in inflammatory changes within the tendon; including tenocyte apoptosis, loss of structural integrity and eventual tearing. Calcific tendonitis may also occur and contribute [6]. Neer’s extrinsic theory [7] describes tears occurring due to impingement caused by surrounding structures (acromial spur or tilt, acromioclavicular joint spur or arthritis and an os-acromiale) during normal motion arc which leads to a continuum of impingement, partial and eventual full RCT. Additionally, acromial morphology is a component of the extrinsic theory as proposed by Bigliani [8] in which they describe an initiating factor leading to rotator cuff dysfunction and eventual tearing. Consequently, it has been advocated that acromioplasty is an integral part of RCT treatment. Originally classified on outlet view radiographs, described acromion morphology includes flat, curved and hooked with prevalence of 12%, 56% and 29% respectively. A hooked and curved acromion has been associated with RCT. Operative treatment is indicated in symptomatic patients when nonoperative management fails. In the absence of joint arthrosis, arthroscopic RCR, if possible, is well established treatment, and this is one of the most frequently performed shoulder surgeries [9]. If successful, improved biomechanics, pain and function can be expected. However, debate exists regarding the requirement of subacromial decompression during rotator cuff repair. This review aims to discuss the role of subacromial decompression in rotator cuff repair and current literature related to the topic.