A 53-year-old, right-handed woman with severe pain and loss of active abduction presented to our hospital with complaints that had started 1 year ago after an open acromioplasty procedure performed for impingement syndrome in another clinic. At that time, radiological studies had revealed an intact bony structure with a type III acromion and no tear had been noted in the rotator cuff in the MR images. A standard open anterior acromioplasty was performed under general anesthesia; the surgeon had not mentioned any perioperative complication or signs of any problem during surgery. An aggressive physical therapy protocol had been prescribed, and active and passive free range of motion was allowed immediately after surgery. A month after the operation the patient started complaining of weakness of her shoulder, especially with regard to her ability to abduct her arm. Physical therapy was continued for 3 months following surgery, after which the patient stopped attending the sessions. She consulted specialists at several different institutions and all advised conservative therapy. Conservative therapy continued unsuccessfully until the patient was referred to the senior author's institution for further evaluation.
At the time of presentation to the senior author's institution, 1 year after the index operation, the patient complained of excessive pain that awakened her from her sleep and severely limited her daily activities. On physical examination of the right shoulder, an unconventional matured incision scar was visible . Her right acromion was readily palpable and the bulk of the deltoid muscle could be easily palpated over the superior portion of the arm with attempts at shoulder abduction. The active range of motion (ROM) of the right shoulder was severely limited: active scapular abduction was 50° and both active external and internal rotations were limited to 10° each. Her passive scapular abduction was 120° and passive external and internal rotations were 25° and 20°, respectively. Impingement sign could not be evaluated due to the overall painful condition of the shoulder.
The unconventional acromioplasty open incision scar. The white arrow shows the detached deltoid insertion.
Based on the findings on physical examination and the history, rotator cuff tear, subacromial impingement syndrome, calcific tendonitis, axillary nerve palsy, and deltoid muscle detachment were all considered in the differential diagnoses. Careful review of the plain radiographs taken between the index and the second surgeries gave valuable information regarding the progress of the pathology. A plain anteroposterior radiograph of the right shoulder which was taken 1 month after the index surgery showed evidence of partial lateral acromionectomy, with the deltoid muscle retracted to the level of the greater tuberosity. The magnetic resonance imaging (MRI) showed that the deltoid muscle mass had retracted about 3 cm distal to the greater tuberosity which was additionally marked by an ossified tissue. We were not able to see the rotator cuff tear and the calcific tendonitis. Electromyographic (EMG) studies of the right upper extremity muscles were all normal except in the case of the deltoid muscle. The right axillary nerve conduction study showed that the distal latency was 2.8 msec (normal) and the compound muscle action potential amplitude was 4.5 mV (normal). The study was interpreted as decreased recruitment in the deltoid muscle. The diagnosis was made based on history, physical examination, the radiological studies, and the EMG study. The patient underwent a delayed primary repair of the deltoid muscle detachment, which had resulted from the excessive acromioplasty.
Through a standard modified acromioplasty incision, which extended from a point over the medial and inferior part of the coracoid to a point lateral to the acromion, the skin and the subcutaneous tissues were carefully dissected. There were extensive adhesions and fibrosis of an abnormal scar tissue that did not represent muscle or tendon tissue. After debridement of the scar tissue, the acromion could be visualized. The deltoid muscle that is normally encountered at this stage of the dissection was absent. A mass of a tissue lying deep in the wound was assumed to be the deltoid muscle. Because the scar tissue had extensively covered the deltoid musculotendinous origin, this structure could not be differentiated. The dissection was extended over the acromion posteriorly until the point where healthy attachments of the deltoid muscle to the acromion were seen. The deltoid muscle tendon was then traced to exactly locate the portions detached away from the acromion. Detached parts of the tendon and the muscle mass had loosely adhered to the proximal humerus distal to the greater tuberosity. We carefully dissected away the useless scar tissue at the origin of the muscle before performing a thorough examination of the rotator cuff by rotating the humerus internally and externally until every part of the rotator cuff was visualized. The rotator cuff looked continuous and healthy. Multiple Mason-Allen sutures were passed through the deltoid muscle-tendon junction to get a good hold of the muscle . While holding on to the sutures, the adhesions between the muscle and the humeral bone were separated by gentle blunt dissection. During the separation, the axillary nerve was identified and all care was taken to avoid damage to it. Ethibond sutures were then passed through the remaining acromion so that the deltoid origin would be approximated to the superior part of the acromion [Figure and ]. The sutures were tied with the arm in 90° abduction.
The adhesions between the proximal deltoid tendon and the proximal humerus are completely detached and the deltoid is put on a secure sling
Secure fixation of the proximal deltoid to the acromion
Schematic drawing of secure fixation of the proximal deltoid to the acromion. RC: rotator cuff, DM: deltoid muscle, Ac: acromion
Postoperatively, the arm was immobilized in 90° abduction for 3 weeks with a custom-made, adjustable arm holder. Starting at the third week, the arm holder was adjusted at weekly intervals, reducing the amount of abduction by 15° every week. Passive abduction was allowed for the remaining abduction range of motion. Active or passive elbow and wrist motion was allowed, starting from postoperative day 1. At 6 weeks postoperatively, aggressive physical therapy and rehabilitation was started to regain range of motion of the shoulder joint and strength of the arm muscles.
At the postoperative third month, the patient was able to perform her activities of daily living and by the sixth month she reported that her shoulder was almost back to normal. At the latest follow-up (25 months postoperatively), she had no functional limitation, was fully involved in her daily household activities, and could take care of her grandchildren . The MR images taken 2 years after the second operation showed anatomical healing of the proximal deltoid muscle onto the acromion.
Both arms comfortably reaching the hair, representing functional external rotation and almost full scapular elevation of both arms