Scapulothoracic fusion

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.

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.

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.

Thoracoscapular Fusion for Winging of the Scapula with Screw Fixation for Fascioscapulohumeral Dystrophy (Modified Copeland-Howard Procedure)

INTRODUCTION

This article describes our technique of thoracoscapular fusion with screw fixation for treatment of winging of the scapula in patients with fascioscapulohumeral dystrophy.

STEP 1 PREOPERATIVE EVALUATION

Perform the Horwitz test.

STEP 2 POSITION THE PATIENT AND MARK THE SKIN FOR THE OPERATION

With the patient on a Montreal mattress, position the arms in 90° to 110° of elevation in the scapular plane and approximately 90° of external rotation and mark the skin.

STEP 3 SURGICAL APPROACH

Make an incision along the medial scapular edge, incise the trapezius muscle, and detach the levator scapula, rhomboid major, and rhomboid minor muscles.

STEP 4 PREPARE THE SCAPULA

Do not decorticate the scapula to avoid weakening it.

STEP 5 SELECT AND PREPARE THE RIBS

Expose three or four ribs subperiosteally, from their superior border to avoid the neurovascular bundle.

STEP 6 DRILL THE SCAPULA AND RIBS

Drill the ribs with a McDonald dissector underneath them to prevent damage to the pleura.

STEP 7 HARVEST AND INTRODUCE BONE GRAFT OR USE BONE-GRAFT SUBSTITUTE AND CLOSE

Pack bone chips or bone-graft substitute between the ribs and the deep surface of the scapula.

STEP 8 POSTOPERATIVE IMMOBILIZATION AND REHABILITATION

An adjustable brace with the arm in 60° of abduction and 30° of forward flexion is worn for three months.

RESULTS

Between July 1997 and July 2010, a thoracoscapular fusion was performed in thirty-five shoulders of twenty-four patients with fascioscapulohumeral dystrophy15.IndicationsContraindicationsPitfalls & Challenges.

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.

The outcome of scapulothoracic arthrodesis using cerclage wires, plates, and allograft for facioscapulohumeral dystrophy

BACKGROUND

Scapulothoracic arthrodesis is a recognized treatment for impaired shoulder function in patients with facioscapulohumeral dystrophy (FSHD) and is traditionally performed with autograft. The purpose of the study was to report our experience with scapulothoracic arthrodesis in patients with FSHD using allograft, rather than autograft, with particular respect to the effect of fusion on preoperative and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores; forced vital capacity (FVC); and complications.

MATERIALS AND METHODS

The early results of 14 consecutive scapulothoracic arthrodeses in FSHD patients with cerclage wires, plates, and allograft (fresh-frozen femoral heads) are reported. DASH scores were recorded preoperatively and 6 months postoperatively. Preoperative and 6-month FVCs were compared. The surgical technique is described.

RESULTS

Eleven patients underwent 14 fusions. The mean follow-up period was 29 months (range, 6-50 months). Forward flexion improved from 70° to 115° (P = .001) and abduction from 68° to 109° (P = .007). The DASH score improved from 48 points to 34 points (P = .005). FVC decreased from 98% to 92% of predicted (P = .021), although this was not clinically significant. One patient required revision for nonunion, and metalwork was removed in 5 scapulae. A postoperative chest infection developed in 1 patient and a pleural effusion in another. One brachial plexus palsy occurred, which had almost completely resolved by 27 months postoperatively.

CONCLUSION

Scapulothoracic arthrodesis can be performed successfully with allograft. The nonunion and complication rates are similar to those in the existing literature. A small decrease in FVC does occur but not to a clinically significant level.

Multidisciplinary approach to the management of myopathies

PURPOSE OF REVIEW

Aside from some inflammatory myopathies and very few genetic disorders, there are no therapies that make most patients with myopathies stronger. Consequently, the management of these patients can be frustrating for patients and their families as well as the clinicians taking care of them. Treatment of these patients must involve a comprehensive approach focused on limiting the secondary effects of skeletal muscle weakness, managing comorbidities associated with specific diseases, and, most importantly, optimizing patients' functional abilities and quality of life in terms of their ability to accomplish activities of daily living. While the approach to each patient differs depending on their disease, certain common themes can be addressed in each patient. This review highlights an approach centered on four conceptual themes ("the Four S's"): Strength therapies, Supportive care, Symptomatic therapies, and pSychological support.

RECENT FINDINGS

Although relatively few well-designed studies have been done that highlight conservative management of patients with various myopathies, an emerging literature helps guide the clinician in certain key areas, especially in relation to cardiac and pulmonary management of these patients.

SUMMARY

While disease-altering therapies have proven elusive for many muscle diseases, a multimodal approach to the conservative and supportive care of these patients can markedly improve their quality of life. Pharmacologic treatment options for specific myopathies will not be addressed in this article but are covered elsewhere in this issue of CONTINUUM.