Second generation surgery
Whereas first generation surgery can be performed with minimal instrumentation, second generation surgery requires powered instruments. Arthroscopic subacromial decompression (ASD) also requires an electrosurgical diathermy apparatus to speed up the procedure and control bleeding, although many surgeons make do without.
Synovectomy can be performed in rheumatoid arthritis, but is technically difficult due to bleeding and the results are as yet unknown. In Ogilvie Harris' series,3 12 of 15 patients undergoing synovectomy for rheumatoid arthritis had significant benefit at 1-2 years' follow-up.
Debridement can be performed in patients with mild osteoarthritis, a full radius resector being used to clean up the joint generally. In 43 patients in Ogilvie Harris' study,3 13 had mild arthritis and 69 per cent of these did well compared to only 37 per cent of the 30 with severe arthritis.
Most surgeons would combine debridement of a cuff tear with subacromial decompression, and results of this are given in Chapter 8. The largest series of cuff debridement without decompression was again that of Ogilvie Harris,3 who reported on 174 patients. In those patients with stage 1 impingement (tendonitis), 67 per cent were successful. However, in those patients with stage 2 (partial thickness tear) the results dropped to only 40 per cent successful and, in those with full thickness tears, the results fell even further to only 17 per cent successful results.
Coracoacromial ligament division
Most surgeons no longer perform coracoacromial ligament division alone, but instead arthroscopic subacromial decompression. Ogilvie Harris3 published his group's results from division alone in 51 patients, 25 of whom had mechanical division and 26 electrocautery division. As only 11 of the 51 patients had a satisfactory outcome, the group concluded that this procedure should be abandoned.
Arthroscopic subacromial decompression (ASD)
This is covered in more detail in Chapter 8.