Open or Closed Surgery?
Before electing for closed surgery, both surgeon and patient must be convinced of its superiority over open surgery. Presently this is debatable.
The method of open surgery has been described by Neer: 2 cm of anterior deltoid are released from the anterior acromion and the coracoacromial ligament and anteroinferior acromion are excised. Any osteophytes under the acromioclavicular joint are excised and the rotator cuff is checked for evidence of tears. The deltoid is then carefully reattached and the skin closed. Hawkins reviewed 108 patients who underwent open acromioplasty, and who had no cuff tear. All patients had shoulder pain for over 1 year before operation, despite conservative treatment. Open acromioplasty was successful in 87 per cent of patients. The operation was less successful in women, those with limited preoperative movement, those who were involved in work compensation, and those whose pain had started after direct trauma. In most surgeons' hands, closed acromioplasty is not as successful as this, although the recent results of Ellman and Kay at 85 per cent satisfactory for stage 2 impingement and of Alcheck et al at 82 per cent excellent and good are comparable.
There is no doubt that arthroscopic subacromial decompression (ASD) is both more difficult and generally takes longer than open procedure. Although ASD has these drawbacks, and tends not to be as successful as open acromioplasty, it does have advantages. These are that it is a day-case procedure, for some reason it is less painful, and the patient has faster rehabilitation. There is no doubt that arthroscopic surgery has a good image amongst the population at large and, to an extent, the patient now demands minimally invasive surgery if possible.