The outcome of scapulothoracic fusion for painful winging of the scapula in dystrophic and non-dystrophic conditions

Scapulothoracic tenodesis using hamstring tendon graft for treatment of problematic scapula winging: A new surgical technique

Introduction

Winging of the scapula occurs due to dysfunction of its stabilising muscles, most commonly serratus anterior and/or trapezius, for example in facioscapulohumeral muscular dystrophy. Resultant loss of scapular control and abnormal kinematics can decrease shoulder function due to glenohumeral joint instability, loss of range of motion and pain. Previously described treatment for cases resistant to physiotherapy includes scapulothoracic arthrodesis which involves risk of non-union and metalwork failure, as well as reduced respiratory function due to immobilisation of a segment of the adjacent chest wall.

Technique

We present a novel surgical approach to the management of problematic scapular winging by using hamstring graft to achieve a scapulothoracic tenodesis.

Discussion

We believe this technique provides an adequately stable scapula for improved shoulder movement and function, a sufficiently mobile chest wall for improved lung function and avoidance of complications specifically associated with arthrodesis.

Which Components of the Simple Shoulder Test Show Improvement After Scapulothoracic Fusion for Recalcitrant Scapular Winging? Clinical Results at a Minimum of 5 Years of Follow-up

BACKGROUND

Scapular winging is an uncommon but important cause of shoulder pain and disability. Surgical management can include soft tissue procedures such as split pectoralis major transfer, the Eden-Lange procedure, or a triple tendon transfer. When these procedures do not alleviate symptomatic winging or are inappropriate, scapulothoracic fusion is an alternative, but data on its longer-term effectiveness are sparse.

QUESTIONS/PURPOSES

(1) What changes in outcome scores were observed (VAS, Single Assessment Numeric Evaluation [SANE], and Simple Shoulder Test [SST] scores), and what proportion of the patients improved by an amount larger than the minimum clinically important difference (MCID) for the outcome tool in question? (2) Which components of the SST are patients able to perform at a minimum of 5 years? (3) What complications occurred after surgery?

METHODS

We performed a retrospective study in a single, large, urban referral medical center of patients who underwent scapulothoracic fusion. Between January 2011 and November 2016, 15 patients underwent scapulothoracic fusion to treat symptomatic scapular winging. Only patients with nondystrophic etiology were included in the analysis (n = 13). Of the 13 remaining patients, one patient was lost to follow-up and another patient died during data collection, leaving 11 patients for the final analysis. Six patients had brachial plexus injuries affecting multiple nerve roots and periscapular muscles, and five had persistent symptoms despite prior tendon transfer. The median age of the patients was 43 years (range 20 to 67 years), and there were six male and five female patients. All patients had a minimum of 5 years of follow-up. There was a median follow-up of 79 months (range 61 to 128 months). The VAS pain score (range 0 to 10, higher scores represent more pain; MCID = 2), SST score (range 0 to 12, higher scores represent less pain and better shoulder function; MCID = 2.3), and SANE score (range 0 to 100, higher scores represent better shoulder function; MCID = 28) were recorded before surgery and at the most recent follow-up. We compared scores from before surgery with those taken at the most recent follow-up and ascertained the proportion of patients whose improvement exceeded the MCID. The number of patients achieving fusion (as confirmed by a CT image), complications, and reoperations was recorded via a record review as well as direct patient query by telephone.

RESULTS

The median VAS pain score improved from 7 (range 3 to 10) preoperatively to 3 (range 2 to 5) at the latest follow-up (p < 0.001). The median SANE score improved from 30 (range 0 to 60) preoperatively to 65 (range 40 to 85) at the latest follow-up (p < 0.001). The median SST score improved from 0 (range 0 to 9) to 8 (range 5 to 10) at the latest follow-up (p < 0.001). Ten of 11 patients had improvements exceeding the MCID for VAS, six of 11 had improvements for SANE scores, and nine of 11 had improvements for SST. Preoperative to postoperative improvements in these components of the SST were seen (responses of "yes"): comfort at rest (three of 11 improved to 11 of 11; p < 0.001), sleep comfortably (three of 11 improved to 11 of 11; p < 0.001), place coin on shelf (two of 11 improved to 10 of 11; p < 0.001), lift 1 pound above shoulder (two of 11 improved to eight of 11; p = 0.03), and carry 20 pounds with the arm at side (one of 11 improved to nine of 11; p < 0.001). All 11 patients had successful fusion noted on CT images. There were three complications (progression of glenohumeral arthritis, broken wires, and perioperative chest tube placement) and one reoperation for progression of glenohumeral arthritis with subsequent total shoulder arthroplasty.

CONCLUSION

Patients with recalcitrant symptomatic scapular winging often undergo an exhaustive course of clinical examinations, diagnostic tests, physical therapy, and multiple surgical procedures. Those with brachial plexus palsy with involvement of multiple nerves may continue to have symptoms despite nonoperative management and subsequent soft tissue tendon transfers. Scapulothoracic fusion could be considered for patients with persistent pain and decreased function because of recalcitrant scapular winging who are either not candidates for the procedure or have persistent symptoms despite prior soft tissue procedures.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Scapulothoracic fusion using nonabsorbable suture fixation: surgical technique and review of the literature

Background

Historically, scapulothoracic fusion (STF) is performed using steel wire and plate construct fixation. The purpose of this study is to report a recent fusion achieved through ultra-high-molecular-weight polyethylene-reinforced suture fixation as well as to perform a systematic literature review of techniques, fusion rates, complications, and reoperation.

Methods

Patient data were gathered from chart review and clinical encounters. For the review, MEDLINE, Embase, and Ovid databases were queried for STF cases. Thirty articles reporting on 386 fusion procedures were included.

Results

Including this patient, 5 of 387 (1.3%) STFs have been attempted with fiber suture. Fusion rates of metal-only constructs is 90.8% (346 of 381) with 11.3% (43 of 381) requiring wire removal or trimming because of symptomatic hardware and 7% (27 of 381) causing a postoperative pneumothorax. Although a small sample size, all fiber-suture constructs have achieved union without implant removal and without pneumothorax development. In this patient, fusion was determined radiographically at 6 months with substantial improvement in pain level and function.

Conclusion

Scapulothoracic fusion has benefit to patients to have failed other management options for winged scapula, most commonly those with neurologic trauma or facioscapulohumeral muscular dystrophy. With advancements in surgical options, fiber-suture offers an alternative to steel wire to achieve fusion. Further cases with longer term follow-up are needed to determine if significant differences in outcomes exist between constructs.

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.

Bilateral scapulothoracic arthrodesis for facioscapulohumeral muscular dystrophy: function, fusion, and respiratory consequences

BACKGROUND

Scapulothoracic arthrodesis (STA) has been proposed for the treatment of painful scapular winging in patients with facioscapulohumeral muscular dystrophy (FSHD). However, the rate of osseous fusion is variable, and there is a theoretical risk of reduced respiratory function after bilateral STA.

METHODS

This was a retrospective study of 10 STAs, performed sequentially, in 5 FSHD patients. The surgical technique involved use of a semitubular plate and wire construct with autograft (iliac crest) interposed between the scapula and rib cage. Osseous fusion, respiratory function, and shoulder function were evaluated. The mean follow-up period was 141 ± 67 months (range, 24-225 months).

RESULTS

Early complications included 1 pneumothorax and 1 pleural effusion. No late complications occurred, and no patients underwent reoperation. On postoperative computed tomography images, complete bony union of the scapula to the ribs was observed in 90% of shoulders (9 of 10). Comparison of preoperative and postoperative pulmonary function test results showed no significant difference in vital capacity (from 87% ± 14% to 85% ± 12%) and forced vital capacity (from 86% ± 16% to 77% ± 15%). Patients gained on average 40° of active forward elevation (from 62° ± 20° to 102° ± 4°) and 22° of abduction (from 58° ± 21° to 89° ± 7°) (P < .001). The mean Subjective Shoulder Value increased from 25% ± 8% to 72% ± 18% (P < .001). All patients were pleased with the results and would recommend the procedure to other persons.

CONCLUSION

In patients with FSHD, bilateral STA provides satisfactory shoulder function with a high rate of scapulothoracic fusion and few or no significant respiratory repercussions.

Functional Outcomes and Complications Following Scapulothoracic Arthrodesis in Patients with Facioscapulohumeral Dystrophy

BACKGROUND

Facioscapulohumeral dystrophy (FSHD) is an autosomal-dominant myopathy characterized by facial and shoulder girdle muscle weakness with scapular winging. Scapulothoracic arthrodesis is a successful treatment approach for patients with <90° of shoulder elevation. The purpose of the present study was to assess functional outcomes and complications following scapulothoracic arthrodesis in patients with FSHD.

METHODS

We retrospectively reviewed the records of 40 patients (64 shoulders) in whom scapulothoracic arthrodesis was performed. To achieve fusion, multiple multifilament cables were used together with autologous bone and allograft bone. Preoperative and postoperative shoulder elevation and abduction; Disabilities of the Arm, Shoulder and Hand (Quick version, qDASH) scores; and pulmonary function were compared. Recorded complications were classified as pulmonary or scapular.

RESULTS

The mean age of the patients at the time of the operation was 25.4 years (range, 15 to 60 years), and the mean duration of follow-up was 71.2 months (range, 12 to 185 months). When the preoperative values were compared with those at the latest follow-up, significant improvement was noted in terms of elevation (from a mean [and standard deviation] of 60.6° ± 17.2° to 123.7° ± 26.7°; p < 0.001), abduction (from 52.7° ± 15.8° to 98.8° ± 20.3°; p < 0.001), and qDASH scores (from 34.7 ± 11.4 to 13.3 ± 13.1; p < 0.001). The overall complication rate was 26.6%. There were 7 pulmonary complications (4 pneumothoraxes, 2 pleural effusions, and 1 major atelectasis), and 5 chest tube placements were required. Ten complications (including 3 rib fractures, 1 brachial plexus palsy, 2 cases of implant irritation, 2 nonunions, 1 delayed union, and 1 scapular fracture) were related to the scapular fixation, and 7 revision procedures were required. Scapulothoracic fusion was achieved in all patients but 1, who had a scapular fracture. Pulmonary function tests were performed for 19 patients, and no difference was observed between preoperative and postoperative results.

CONCLUSIONS

Scapulothoracic arthrodesis with use of multifilament cables is a successful surgical technique with high fusion rates and low morbidity. Pulmonary complications are common but resolve with careful attention.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anatomy, Etiology, and Management of Scapular Winging

Scapular winging is a painful and debilitating condition. The composite scapular motion of rotation, abduction, and tilting is necessary for proper shoulder function. Weakness or loss of scapular mechanics can lead to difficulties with elevation of the arm and lifting objects. The most common causes reported in the literature for scapular winging are dysfunction of the serratus anterior from long thoracic nerve injury causing medial winging or dysfunction of the trapezius from spinal accessory nerve injury causing lateral winging. Most reviews and teaching focus on these etiologies. However, acute traumatic tears of the serratus anterior, trapezius, and rhomboids off of the scapula are important and under-recognized causes of scapular winging and dysfunction. This article will review the relevant anatomy, etiology, clinical evaluation, diagnostic testing, and treatment of scapular winging. It will also discuss the differences in diagnosis and management between scapular winging arising from neurogenic causes and traumatic muscular detachment.

Split Pectoralis Major Transfer for Chronic Medial Scapular Winging

Scapular winging can be a significant source of chronic pain, weakness, and disability of the shoulder. Isolated serratus anterior palsy from long thoracic nerve injury, which is the most common cause of this condition, produces prominent winging and medial malpositioning of the inferior angle of the scapula. In the case of persistent symptoms despite conservative care, treatment options primarily include scapulothoracic fusion and pectoralis major transfer. Outcomes of scapulothoracic fusion are notable for a high complication rate and limited functional improvements. We describe our technique of indirect, split pectoralis major transfer to the inferolateral scapula with allograft tissue augmentation for the surgical treatment of chronic medial winging. This procedure provides dynamic stabilization of the scapula with secure and tension-free tendon transfer. Advantages over alternative treatments include a relatively low complication rate, acceptable cosmesis, and better range of motion. The rationale and technical aspects of this procedure are discussed. Additional clinical studies are warranted to compare outcomes for the direct and indirect split transfer methods.

Long-term results of Letournel scapulothoracic fusion in facioscapulohumeral muscular dystrophy: A retrospective study of eight cases

BACKGROUND

The aim of this study was to evaluate long-term radio-clinical outcome in scapulothoracic fusion using the Letournel technique (where the fourth rib is passed through the wing of the scapula and cerclage wires are tightened to the two ribs below) for patients suffering from facioscapulohumeral muscular dystrophy (FSHMD), a degenerative pathology affecting scapula-stabilizing muscles, leading to scapular winging, shoulder pain and restricted shoulder abduction and flexion, despite a functional deltoid muscle.

METHODS

This retrospective study, with an average follow-up of 14 years (168 months; σ=73 months), included four patients who underwent a bilateral procedure, one side after the other, with shoulder abduction and flexion gain as primary endpoints.

RESULTS

Mean improvement in range of motion was 36° (σ=32°) in abduction and 40° (σ=44°) in flexion. Postoperatively, active abduction averaged 99° (σ=28°) and active flexion 110° (σ=45°). In one case, a 58 year-old patient, gain in motion was 50° for abduction and 60° for anterior elevation. In one patient, range of motion showed bilateral decrease due to the natural course of the FSHMD. No intraoperative complications were reported.

DISCUSSION

The Letournel technique seems to be an effective long-term solution in FSHMD, without age limit. Improvements appear to be steady over time, the only long-term limitations being the natural course of the disease itself.

LEVEL OF EVIDENCE

IV - retrospective case series.

Changes in the loadings on the shoulder girdle in the case of scapulothoracic fusion

BACKGROUND

Scapulothoracic fusion (STF) may be an alternative and salvage procedure in the treatment of scapular winging. The biomechanical effects of this procedure on the shoulder girdle have not been previously considered. The purpose of this study is to demonstrate the relationship between STF and the stress distribution pattern of the shoulder girdle.

METHODS

Three-dimensional solid modeling of the shoulder girdle was carried out using virtual finite element modeling. STF was applied to the reference model obtained in a computer environment. Dynamic and nonlinear analysis was performed.

RESULTS

Stress distributions in joints and ligaments were calculated. With respect to loading on the joints, maximum equivalent stresses increased on acromioclavicular (AC) and GH joints in the case of STF during abduction and flexion respectively.

CONCLUSION

Results revealed that STF is a non-physiological, static procedure leading to load increase on GH and AC joint cartilages, which may be a cause of potential joint osteoarthritis. Copyright © 2015 John Wiley & Sons, Ltd.

Scapulothoracic fusion: outcomes and complications

BACKGROUND

Scapulothoracic fusion (STF) may be an option to alleviate pain and restore function. The purpose of this study is to report the clinical outcome of patients who underwent STF for the treatment of painful scapular winging.

MATERIALS AND METHODS

From 1999 through 2008, 10 patients (12 shoulders) underwent an STF for painful winging of the scapula. The mean follow-up period was 41 months (range, 8-72 months). Indications for STF included winging in association with excessive medial and/or lateral clavicular resection and facioscapulohumeral dystrophy, as well as scapular winging related to combined long thoracic and spinal accessory nerve palsy. A retrospective review was performed to evaluate the subjective shoulder value, visual analog scale score, range of motion, unions, and complications.

RESULTS

There was a statistically significant improvement in the subjective shoulder value, visual analog scale score, range of motion, and satisfaction postoperatively. The overall complication rate was 50% (6 of 12). There were 2 persistent nonunions (2 of 12, 17%), and 50% (6 of 12) of all fusions required subsequent hardware removal because of discomfort. Complications included pleural effusion (3 of 12, 25%), hemopneumothorax (1 of 12, 8%) pulmonary embolus (1 of 12, 8%), and infection (1 of 12, 8%). With the exception of the revision nonunion, all complications resolved with no negative sequelae.

CONCLUSION

STF results in improved function and pain relief. STF is associated with a high short-term complication rate with limited long-term sequelae.

Scapular Winging

This review explores the causes of scapula winging, with overview of the relevant anatomy, proposed aetiology and treatment. Particular focus is given to lesions of the long thoracic nerve, which is reported to be the most common aetiological factor.