Arthroscopic Pectoralis Minor Release

Radiofrequency in arthroscopic shoulder surgery: a systematic review

BACKGROUND

Radiofrequency has seen an increase in use in orthopedics including cartilage lesion debridement in the hip and knee as well as many applications in arthroscopic shoulder surgery. The purpose of this systematic review is to evaluate the safety and usage of radiofrequency in the shoulder.

METHODS

This systematic review was registered with PROSPERO (international registry) and followed the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) guidelines. Embase and PubMed were searched using: "shoulder," "rotator cuff," "biceps," "acromion" AND "monopolar," "bipolar," "ablation," "coblation," and "radiofrequency ablation." The title and abstract review were performed independently. Any discrepancies were addressed through open discussion.

RESULTS

A total of 63 studies were included. Radiofrequency is currently utilized in impingement syndrome, fracture fixation, instability, nerve injury, adhesive capsulitis, postoperative stiffness, and rotator cuff disease. Adverse events, namely superficial burns, are limited to case reports and case series, with higher-level evidence demonstrating safe use when used below the temperature threshold. Bipolar radiofrequency may decrease operative time and decrease the cost per case.

CONCLUSIONS

Shoulder radiofrequency has a wide scope of application in various shoulder pathologies. Shoulder radiofrequency is safe; however, requires practitioners to be cognizant of the potential for thermal burn injuries. Bipolar radiofrequency may represent a more efficacious and economic treatment modality. Safety precautions have been executed by institutions to cut down patient complications from shoulder radiofrequency. Future research is required to determine what measures can be taken to further minimize the risk of thermal burns.

Combined Arthroscopic Scapulothoracic Bursectomy, Partial Scapulectomy, and Pectoralis Minor Release for the Treatment of Snapping Scapular Syndrome

Snapping scapula syndrome (SSS) is a source of pain and discomfort in patients. It is not uncommon for patients who present with SSS to have some degree of scapular dysfunction, especially with the tightness of the pectoralis minor (PM) muscle. In this Technical Note, we demonstrate our preferred technique for arthroscopic scapulothoracic bursectomy and partial scapulectomy with concomitant pectoralis minor release for the treatment of symptomatic SSS and PM tightness. In the treatment of these patients, PM release is beneficial because arthroscopic scapulothoracic bursectomy or partial scapulectomy alone may result in residual scapular dyskinesis.

Novel Diagnostic and Treatment Techniques for Neurogenic Thoracic Outlet Syndrome

Neurogenic thoracic outlet syndrome is a challenging condition to diagnose and treat, often precipitated by the triad of repetitive overhead activity, pectoralis minor contracture, and scapular dyskinesia. The resultant protracted scapular posture creates gradual repetitive traction injury of the suprascapular nerve via tethering at the suprascapular notch and decreases the volume of the brachial plexus cords and axillary vessels in the retropectoralis minor space. A stepwise and exhaustive diagnostic protocol is essential to exclude alternate pathologies and confirm the diagnosis of this dynamic pathologic process. Ultrasound-guided injections of local anesthetic or botulinum toxin are a key factor in confirming the diagnosis and prognosticating potential response from surgical release. In patients who fail over 6 months of supervised physical therapy aimed at correcting scapular posture and stretching of the pectoralis minor, arthroscopic surgical release is indicated. We present our diagnostic algorithm and technique for arthroscopic suprascapular neurolysis, pectoralis minor release, brachial plexus neurolysis, and infraclavicular thoracic outlet decompression.

Arthroscopic Pectoralis Minor Release After Reverse Shoulder Arthroplasty: A Novel Consideration for Postarthroplasty Pain

CASE

A 74-year-old male patient presenting with chronic radiating shoulder pain, paresthesias, and weakness had previously undergone reverse shoulder arthroplasty and anterior cervical discectomy and fusion for an irreparable cuff tear and cervical radiculopathy, respectively. After being diagnosed with neurogenic thoracic outlet syndrome and undergoing physiotherapy, the patient's recalcitrant condition was surgically managed with arthroscopic pectoralis minor tenotomy, suprascapular nerve release, and brachial plexus neurolysis.

CONCLUSION

This ultimately led to complete pain relief and improved function. By sharing this case, we aim to shed light on this overlooked pathology and help prevent unnecessary procedures for others suffering from similar conditions.

Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.

Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome

Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.

Arthroscopic release of the pectoralis minor tendon from the coracoid for pectoralis minor syndrome

Purpose

The term “pectoralis minor syndrome” refers to this constellation of symptoms that can occur when the pectoralis minor (Pm) is shortened and contracted. Release of the tendon of the Pm from the coracoid has been reported to provide substantial clinical improvement to patients presenting with pectoralis minor syndrome. The purpose of this study was (1) to describe the technique for endoscopic release of pectoralis minor tendon at the subdeltoid space, (2) to classify the pectoralis minor syndrome according to its severity and (3) and to report the short-term outcomes of this procedure in a consecutive series of patients diagnosed with pectoralis minor syndrome.

Methods

Endoscopic release of the pectoralis minor tendon was performed in a series of 10 patients presenting with pectoralis minor syndrome. There were six females and four males with a median age at the time of surgery of 42 (range from 20 to 58) years. Four shoulders were categorized as grade I (scapular dyskinesis), and six as grade II (intermittent brachial plexopathy). Shoulders were evaluated for pain, motion, satisfaction, subjective shoulder value (SSV), quick-DASH, ASES score, and complications. The mean follow-up time was 19 (range, 6 to 49) months.

Results

Arthroscopic release of the tendon of the Pm led to substantial resolution of pectoralis minor syndrome symptoms in all but one shoulder, which was considered a failure. Preoperatively, the median VAS for pain was 8.5 (range, 7–10) and the mean SSV was 20% (range, 10% - 50%). At most recent follow-up the mean VAS for pain was 1 (range, 0–6) and the mean SSV 80% (range, 50% - 90%). Before surgery, mean ASES and quick-DASH scores were 19.1 (range, 10–41.6) and 83.1 (range, 71 and 95.5) points respectively. At most recent follow-up, mean ASES and quick-DASH scores were 80.1 (range, 40–100) and 19.3 (range, 2.3–68) points respectively. No surgical complications occurred in any of the shoulder included in this study.

Conclusions

Endoscopic release of the tendon of the pectoralis minor from the coracoid improves pain, function and patient reported outcomes in the majority of patients presenting with the diagnosis of isolated pectoralis minor syndrome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00491-x.

Outcome of arthroscopic pectoralis minor release and scapulopexy for the management of scapulothoracic abnormal motion

BACKGROUND

Management of persistent symptomatic scapulothoracic abnormal motion (STAM) in the absence of periscapular muscle paralysis may be challenging. This study reports the outcomes of arthroscopic pectoralis minor release and scapulopexy for the management of symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity in the absence of periscapular paralysis.

METHODS

This was a retrospective cohort study with prospectively collected data of patients with symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity. Surgery was indicated if patients failed 6 months of conservative management. Patient outcomes were assessed with shoulder range of motion (ROM) measurements, numerical pain scale, shoulder subjective value (SSV), and Constant score. Data were analyzed with Fischer's exact test for categorical variables and Student's t-test of unequal variance for continuous and categorical variables.

RESULTS

Thirty-one consecutive patients were included in the study period between 2017 and 2020. Average age at the time of surgery was 24 years (range, 14-44 years), 80% of patients were female, and average follow-up after surgery was 23 months (range, 15-39 months). Thirteen patients also had a diagnosis of recurrent posterior instability. At final follow-up, 81% reported significant improvements in their STAM, as demonstrated by improved mean pain scale, ROM, SSV, and Constant scores. Pain improved from 6 (range, 4-10) to 2 (range, 1-4), SSV from 30% (range, 10%-40%) to 75% (range, 60%-100%), and Constant score from 49 (range, 43-61) preoperatively to 79 (range, 51-100) postoperatively (P < .01). All 13 patients with recurrent associated posterior instability had resolution of their instability. Flexion ROM improved from average 100° (range, 60°-150°) to 140° (range, 120°-160°). One patient had traumatic rupture of her scapulopexy 7 weeks postoperatively and underwent revision scapulopexy. Thirteen percent had minimal improvement after surgery and experienced recurrence 3 months postoperatively.

CONCLUSION

In patients with symptomatic STAM secondary to pectoralis minor hyperactivity and serratus anterior hypoactivity, arthroscopic pectoralis minor release and scapulopexy is an effective surgical option.

Arthroscopic release of the pectoralis minor tendon as an adjunct to acromioplasty in the treatment of subacromial syndrome associated with scapular dyskinesia

INTRODUCTION

One of the causes of scapular dyskinesia is the retraction of the pectoralis minor muscle. It can be the cause of shoulder pain associated with increased anterior tilt and internal rotation of the shoulder.

HYPOTHESIS

Arthroscopic release of the pectoralis minor tendon is effective for shoulder pain, linked to a correction of dyskinesia, resulting in the early disappearance of scapulalgia.

PATIENTS AND METHODS

This was a retrospective, monocentric, single-surgeon study on a continuous series of patients with symptomatic shoulder pain, related to subacromial impingement associated with scapular dyskinesia. The series underwent arthroscopic tenotomies of the pectoralis minor between January 2015 and September 2018. Fifty-eight releases were performed to 57 patients (22 males, 35 females), with a mean age of 51.4 years (29-66 years). In all cases, they presented pain on palpation of the upper bundle of the trapezius muscle, and on palpation of the coracoid insertion of the pectoralis minor.

RESULTS

Preoperatively, there were 30 cases of stage 1 scapular dyskinesia and 28 cases of stage 2, with a scapular index measured at 53.84 (41.66-65.78), while the constant score was 41.46 (19-59). Upper trapezius pain was present in 87.7% of cases. The 57 patients were clinically assessed, with a mean follow-up of 8.9 months (6-24 months). Post-operatively, 15 cases (25.8%) of scapulalgia persisted at 2 months of follow-up, while upper trapezius pain was present in only 22.4%. Scapular dyskinesia was no longer present at 2 months in patients without scapulalgia. The scapular index was measured at 60.42 (52.38-70.96), and the constant score at last follow-up was 76.36 (42-92).

CONCLUSION

Tenotomy of the pectoralis minor improves painful symptomatology and scapular dyskinesia, in cases of subacromial syndrome with retraction of the pectoralis minor muscle.

LEVEL OF EVIDENCE

IV, retrospective study.

Literature Review of Anatomical Variations: Clinical Significance, Identification Approach, and Teaching Strategies

This article is a comprehensive literature review on anatomical variations, shedding some light on their clinical significance, identification approaches, and teaching strategies. Anatomical variation is a normal presentation of body structure with morphological features different from those that have been classically described in several anatomy textbooks. Under normal circumstances, it has no impact on the function of the structure. However, it may influence different aspects of clinical practice. As a result, accurate knowledge of common anatomical variations in the treated area may improve clinical practice outcomes. On the other hand, anatomical variations are usually identified during routine dissection and clinical practice, including preoperative imaging and surgical procedures. Additionally, scientific research, such as observational studies using cadaveric dissection, medical images, and evidence-based anatomy, are effective approaches to identify anatomical variations. With regard to the teaching of anatomical variations, cadaveric dissection is the most commonly used and recommended learning tool for teaching anatomy and relevant variations in medical schools. However, the literature emphasizes introducing anatomical variations in the clinical phase of medical curricula and postgraduate training of surgical and radiological programs. The current study suggests creating a registry of anatomical variations encountered during practice that may enhance best care and prevent any confusion about those variations. In addition, there is a need to conduct more educational studies to research the best learning strategies for teaching and assessing anatomical variations in the medical curricula.