Arthroscopic management of snapping scapula syndrome improves pain and functional outcomes, although a high rate of residual symptoms has been reported

Minimum 5-Year Clinical and Return-to-Sport Outcomes After Primary Arthroscopic Scapulothoracic Bursectomy and Partial Scapulectomy for Snapping Scapula Syndrome

BACKGROUND

Snapping scapula syndrome (SSS) is a rare condition that is oftentimes debilitating. For patients whose symptoms are resistant to nonoperative treatment, arthroscopic surgery may offer relief. Because of the rarity of SSS, reports of clinical outcomes after arthroscopic SSS surgery are primarily limited to small case series and short-term follow-up studies.

PURPOSE

To report minimum 5-year clinical and sport-specific outcomes after arthroscopic bursectomy and partial scapulectomy for SSS and to identify demographic and clinical factors at baseline associated with clinical outcomes at minimum 5-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent arthroscopic bursectomy and partial scapulectomy for SSS between October 2005 and February 2016 with a minimum of 5 years of postoperative follow-up were enrolled in this single-center study. Clinical outcome scores, including the 12-Item Short Form Health Survey (SF-12), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) score for pain, were collected at a minimum 5-year follow-up. Additionally, it was determined which patients reached the minimal clinically important difference. Bivariate analysis was used to determine whether baseline demographic and clinical factors had any association with the outcome scores.

RESULTS

Of 81 patients eligible for inclusion in the study, follow-up was obtained for 66 patients (age 33.6 ± 13.3 years; 31 female). At a mean follow-up of 8.9 ± 2.5 years (range, 5.0-15.4 years), all of the outcome scores significantly improved compared with baseline. These included the ASES (from 56.7 ± 14.5 at baseline to 87.2 ± 13.9 at follow-up; P < .001), QuickDASH (from 38.7 ± 17.6 to 13.1 ± 14.6; P < .001), SANE (from 52.4 ± 21.2 to 82.7 ± 19.9; P < .001), SF-12 Physical Component Summary (from 39.7 ± 8.3 to 50.3 ± 8.2; P < .001), SF-12 Mental Component Summary (from 48.2 ± 11.7 to 52.0 ± 9.0; P = 0.014) and VAS pain (from 5.2 ± 2.1 to 1.4 ± 2.0; P < .001). The minimal clinically important difference in the ASES score was reached by 77.6% of the patients. Median postoperative satisfaction was 8 out of 10. It was found that 90.5% of the patients returned to sport, with 73.8% of the patients able to return to their preinjury level. At the time of final follow-up, 8 (12.1%) patients had undergone revision surgery for recurrent SSS symptoms. Older age at surgery (P = .044), lower preoperative SF-12 Mental Component Summary score (P = .008), lower preoperative ASES score (P = .019), and increased preoperative VAS pain score (P = .016) were significantly associated with not achieving a Patient Acceptable Symptom State on the ASES score.

CONCLUSION

Patients undergoing arthroscopic bursectomy and partial scapulectomy for SSS experienced clinically significant improvements in functional scores, pain, and quality of life, which were sustained at a minimum of 5 years and a mean follow-up of 8.9 years postoperatively. Higher patient age, inferior mental health status, increased shoulder pain, and lower ASES scores at baseline were significantly associated with worse postoperative outcomes.

Arthroscopic scapulothoracic bursectomy with and without superomedial angle scapuloplasty: a comparison of patient-reported outcomes

BACKGROUND

Operative treatment of scapulothoracic bursitis most commonly comprises arthroscopic scapulothoracic bursectomy with or without partial superomedial angle scapuloplasty. There is currently no consensus regarding whether or when scapuloplasty should be performed. Prior studies are limited to small case series, and optimal surgical indications are not yet established. The purposes of this study were (1) to retrospectively review patient-reported outcomes of arthroscopic treatment of scapulothoracic bursitis and (2) to compare outcomes between scapulothoracic bursectomy alone and bursectomy with scapuloplasty. We hypothesized that bursectomy with scapuloplasty would provide superior pain relief and functional improvement.

MATERIALS AND METHODS

All cases of scapulothoracic débridement with or without scapuloplasty completed at a single academic center from 2007 through August 2020 were reviewed. Patient demographic characteristics, symptomatology data, physical examination findings, and corticosteroid injection response data were collected from the electronic medical record. Visual analog scale pain, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Single Assessment Numeric Evaluation scores were collected. Comparisons between the group undergoing bursectomy alone and the group undergoing bursectomy with scapuloplasty were made using the Student t test for continuous variables and the Fisher exact test for categorical variables.

RESULTS

Thirty patients underwent scapulothoracic bursectomy alone, and 38 patients underwent bursectomy with scapuloplasty. Final follow-up data were available for 56 of 68 cases (82%). Final postoperative visual analog scale pain scores (3.4 ± 2.2 and 2.8 ± 2.2, respectively; P = .351), American Shoulder and Elbow Surgeons scores (75.8 ± 17.7 and 76.5 ± 22.5, respectively; P = .895), and Simple Shoulder Test scores (8.8 ± 2.3 and 9.5 ± 2.8, respectively; P = .340) were similar between the bursectomy-alone and bursectomy-with-scapuloplasty groups.

CONCLUSION

Both arthroscopic scapulothoracic bursectomy alone and bursectomy with scapuloplasty are effective treatments for scapulothoracic bursitis. Operative time is shorter without scapuloplasty. In this retrospective series, these procedures showed similar outcomes regarding shoulder function, pain, surgical complications, and rates of subsequent shoulder surgery. Further studies with a focus on 3-dimensional scapular morphology may help optimize patient selection for each of these procedures.

Scapulothoracic Arthroscopy for Snapping Scapula Syndrome

Background:

Snapping scapula syndrome (SSS) is a disruption of the normal smooth motion of the scapulothoracic joint leading to clicking or “snapping” which can be painful or painless. There are a variety of etiologies with first-line treatment being conservative. If patients fail extensive nonoperative treatments, then surgery may be considered. Although technically challenging, arthroscopic treatment is recommended due to its decreased morbidity and improved cosmesis.

Indications:

We present a 21-year-old man with a 2-year history of mechanical popping and crepitus with overhead and scapulothoracic motion of his left arm. After failing an extensive trial of conservative therapy, the patient underwent scapulothoracic arthroscopy with bursectomy and partial resection of the superomedial border of the scapula.

Technique Description:

The patient is positioned prone with the operative arm behind the back to elevate the medial border off the chest wall. The scapula is outlined. Two arthroscopic portals are used; the superior portal is 3 cm medial to the medial border of the scapula at the level of the scapular spine and the inferior portal is 4 cm inferior to this at the inferomedial angle of the scapula. Viewing is typically done from the inferior portal, and the superior portal is used for resection of the bursa and superomedial border of the scapula. A shaver and ablator are used to perform a bursectomy and expose the superomedial border of the scapula. An arthroscopic bur is used to partially resect the superomedial border of the scapula at approximately 3.5 cm wide and 2 cm deep.

Results:

Although there are limited studies examining outcomes after scapulothoracic arthroscopy, the current literature suggests that scapulothoracic arthroscopy is effective in improving crepitus, pain, and clinical outcome scores.

Discussion/Conclusion:

In cases of SSS which have failed exhaustive conservative therapy, arthroscopic bursectomy and partial bony resection can be an effective treatment option with minimal invasiveness, improved cosmesis, and early return to activities. Proper patient positioning and careful portal placement are critical to avoid iatrogenic injury, particularly to neurologic structures.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Bilateral scapular osteochondroma in Multiple Hereditary Exostosis patient presented with bilateral shoulder pain treated with arthroscopic and open excision: Case report

Introduction and importance

Multiple etiologies for snapping shoulder syndrome have been described in the existing literature. Scapular osteochondroma is considered as a rare etiology and bilateral scapular osteochondroma have rarely been reported to date. Patient can present with discomfort, pain and crepitation. Multiple surgical methods were described and the patient underwent two different surgical methods with preferable outcome for arthroscopic side.

Case presentation

24 year-old male who is known case of Multiple Hereditary Exostosis (MHE) since childhood presented with bilateral shoulder pain and snapping scapula. Computed tomography demonstrated bilateral ventral scapular osteochondromas. One side treated with open excision and other side with arthroscopic excision.

Clinical discussion

Patient exhibited resolution of symptoms, restoration of function on both sides, but he reported cosmetic preference over arthroscopic side and faster recovery from surgery as well in terms of pain resolution and rehabilitation.

Conclusion

Osteochondroma should by one of differential diagnoses for snapping shoulder syndrome. Despite arthroscopic excision is technically demanding, it carries better outcome compared to open excision.

Arthroscopic Management of Scapulothoracic Bursitis: Clinical Outcomes and Assessment of Novel Bony Parameters on Magnetic Resonance Imaging

Background

Scapulothoracic bursitis is a significant clinical condition that limits day-to-day function. Arthroscopic scapular debridement and resection have provided satisfactory outcomes; however, techniques, approaches, and recommendations remain varied. Novel bony parameters have also gained increasing interest owing to their value in preoperative planning.

Purpose

To assess midterm clinical outcomes after the arthroscopic management of scapulothoracic bursitis and to identify and measure novel bony parameters on preoperative magnetic resonance imaging.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 8 patients underwent arthroscopic scapular debridement and bursectomy; 5 of the 8 patients underwent additional medial scapulectomy. There were 5 male (62.5%) and 3 female (37.5%) patients with a mean age of 30.1 ± 12.3 years (range, 19-58 years). Inclusion criteria for surgery were patients with symptomatic scapulothoracic bursitis for whom extensive nonoperative modalities had been utilized for at least 6 months but failed. Outcome measures included the Oxford Shoulder Score (OSS), University of California Los Angeles (UCLA) shoulder rating scale, Constant Shoulder Score (CSS), and visual analog scale (VAS) for pain. The bony parameters included scapular shape, anterior offset, costomedial angle, and medial scapular corpus angle (MSCA).

Results

The follow-up duration was at least 2 years for all patients (mean follow-up, 25.0 ± 4.1 months [range, 24-35 months]). The majority of patients had a concave-shaped scapula (62.5%). The mean anterior offset was 24.3 ± 3.4 mm, and the mean costomedial angle was 132.3° ± 9.6°. Half the patients had a positive MSCA, while the other half had a negative MSCA. A statistically significant improvement was observed in the OSS, UCLA, CSS, and VAS scores from preoperatively to 2-year follow-up (P < .001 for all). No complications were observed.

Conclusion

Arthroscopic scapular debridement and resection provided satisfactory midterm clinical outcomes for the treatment of scapulothoracic bursitis.

Editorial Commentary: Snapping Scapula Syndrome: Predictors of Outcomes After Arthroscopic Treatment

Snapping scapula syndrome and scapulothoracic bursitis are rare, often painful or functionally limiting conditions that can present owing to underlying anatomic abnormalities or can be idiopathic in nature. When there are no underlying structural abnormalities, diagnosis can be challenging and frequently patients will present with chronic pain having received multiple diagnostic and treatment modalities with no success. Injections into the scapulothoracic bursa, in conjunction with physical therapy, have been shown to be effective for the patient with snapping scapula syndrome and/or scapulothoracic bursitis, when recognized. Yet, some cases are recalcitrant to conservative treatment, and surgical intervention is required. As with any procedure, patient selection for surgical intervention is critical and based on the diagnostic workup-particularly, the response to diagnostic or therapeutic injections. The best surgical outcomes may be achieved in patients who receive bursectomy in conjunction with partial scapulectomy, and negative prognostic factors include older age, lower preoperative psychological score, and longer duration of symptoms.

Prognosis After Arthroscopic Superior Medial Scapuloplasty for Snapping Scapula Syndrome Improves After a Transient Beneficial Response With an Ultrasound-Guided Subscapular Cortisone Injection

PURPOSE

To evaluate the prognostic value of an ultrasound-guided subscapular local anesthetic and cortisone injection in a consecutive series of patients who underwent an arthroscopic superior medial scapuloplasty for snapping scapula syndrome (SSS) and had been refractory to conservative treatment.

METHODS

We undertook an arthroscopic superior medial scapuloplasty on patients with a clinical diagnosis of SSS who had failed a structured physiotherapy program and had either gained a good response or no to minimal response to preoperative ultrasound-guided subscapular local anesthetic and cortisone injection. The patients were assessed preoperatively and at final follow-up with the QuickDASH and Constant scores, and their pain was assessed with a visual analog scale (VAS).

RESULTS

Between January 2009 and December 2016, 47 patients were included in the study, with a minimal follow-up of 2 years. There were 29 female and 18 male patients, and the mean age at the time of surgery was 27.4 years (range 15 to 61). Forty-two patients were available at final follow-up. There were 31 patients in the good response group and 11 patients in the no to minimal response group. For all patients, the mean time to follow-up was 41.8 months (range 24 to 108). There was a significant improvement after surgery in the mean QuickDASH score (from 39 to 20, P < .001) (minimal clinically important difference [MCID] 15.91) , Constant score (from 57 to 87, P < .001) (MCID 10.4), and VAS (from 6 to 2, P < .001) (MCID 3). For the good response group, there was a significant improvement after surgery in the mean QuickDASH score (from 38 to 18, P < .001) (MCID 15.91), the Constant score (from 57 to 89) (MCID 10.4), and the VAS (from 6 to 2, P < .001) (MCID 3). For the no to minimal response group, there was a significant improvement after surgery in the mean QuickDASH score (from 42 to 24, P < .01) (MCID 15.91), the Constant score (from 58 to 80, P < .002) (MCID 10.4), and the VAS (from 6 to 2, P < .01) (MCID 3). The difference in postoperative improvement of the QuickDASH and Constant scores between the good response and the no to minimal response groups was statistically significant (P < .05).

CONCLUSION

The results of this study suggest that arthroscopic scapuloplasty can lead to a significant improvement in pain and function in all patients with a clinical diagnosis of snapping scapula syndrome refractory to conservative treatment. Patients who gained a good transient response to a preoperative ultrasound-guided subscapular cortisone injection obtained a significantly better recovery than those who did not. A preoperative ultrasound-guided subscapular cortisone injection appeared to be of prognostic value.