Abstract
Background:
Scapular winging is a rare and often misdiagnosed disorder, which can be painful and functionally limited. Medial scapular winging is often due to serratus anterior dysfunction in the setting of a long thoracic nerve palsy. While nonoperative management can be successful, transfer of the pectoralis major with autograft hamstring augmentation to the inferior scapula is an effective operative means of relieving pain and restoring shoulder function in those who fail conservative management.
Indications:
The patient is a 16-year-old woman with symptomatic medial scapular winging who had a complete workup and 6-month course of conservative treatment, including physical therapy. Thus, we elected to proceed with a 2-incision transfer of the sternal head of pectoralis major transfer with autograft hamstring augmentation to the inferior scapular angle.
Technique Description:
A 2-incision transfer of the sternal head of pectoralis major with autograft hamstring to the inferior scapular angle is a strong and reliable method of operatively treating medial scapular winging. In addition, performing this operation in the lateral position allows for ease of access to both the anterior and posterior incisions.
Results:
At 1-year follow-up, the patient had full, painless range of motion of the shoulder with 5/5 strength in all tested planes. She also had returned to all activities, including softball, without restrictions.
Discussion/Conclusions:
A 2-incision transfer of the sternal head of the pectoralis major with autograft hamstring augmentation to the inferior scapular angle is an effective means of operatively treating medial scapular winging. Multiple studies have shown that this operation improves motion, pain, and function for those who have failed an appropriate course of conservative treatment.
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.
This is a visual representation of the abstract.
Video Transcript
This video is presented by the listed authors from the Medical University of South Carolina.
The authors have no disclosures.
Scapular winging is a rare and often misdiagnosed disorder that was first reported in the literature nearly 300 years ago by Winslow. 1 Periscapular pain and altered scapulothoracic kinematics decrease shoulder strength and limit the ability to abduct the shoulder or perform overhead tasks.
The most common cause of medial scapular winging is serratus anterior dysfunction due to long thoracic nerve palsy. Long thoracic nerve palsy can be secondary to trauma, infection, and idiopathic injuries. Normally, serratus anterior maintains scapular stability by holding the medial scapula to the chest wall during upward rotation and protraction of the scapula. While nonoperative management can be successful, those who do not improve with a trial of conservative treatment meet indications for a dynamic muscle transfer.
This technique video demonstrates our preferred method for surgical correction of medial scapular winging through transfer of the sternal head (SH) of the pectoralis major muscle with autograft hamstring augmentation to the inferior angle of the scapula.
The patient is a right-hand-dominant 16-year-old female softball pitcher with a longstanding history of right shoulder pain and dysfunction. She had undergone a prior scapulothoracic bursectomy surgery without relief of symptoms. In addition, she has trialed conservative measures including medications, injections, physical therapy, and chiropractic treatment without relief. Radiographs show no obvious pathology with the exception of nonpathologic increased capsular volume and a small amount of irregularity of the inferior capsule and labrum on magnetic resonance imaging.
Examination was notable for medial scapular winging and relief of pain with the scapular assistance test. There were no signs of rotator cuff or labral pathology. The patient had not undergone electromyography (EMG) nerve conduction study at this point, so an EMG was recommended for complete workup.
This is a depiction of the serratus anterior muscle.
The patient had a complete workup and extensive trial of conservative treatment. Given persistent symptomatic medial scapular winging, we elected to proceed with a 2-incision transfer of the SH of the pectoralis major with autograft hamstring augmentation to the inferior scapular angle. Radiographs were obtained preoperatively, but were not clinically relevant.
The case is started with the patient positioned supine to allow for harvesting of the allograft hamstring. Subsequently, the patient is positioned in lateral decubitus on a pegboard with the affected arm facing up to perform the pectoralis major tendon transfer.
The case is started with the patient positioned supine to allow for harvesting of the allograft hamstring. A tourniquet is placed on the ipsilateral proximal thigh and the leg is prepped and draped in standard sterile fashion. A vertical anteromedial longitudinal incision at the level of the tibial tubercle is made to expose the pes anserine bursa and sartorius fascia, covering the hamstring tendons. The sartorius fascia is incised to expose the underlying tendons. The semitendinosus and gracilis tendons are identified, isolated, and whipstitched.
Subsequently, each is placed individually through an open tendon stripper and released from its muscular attachment by flexing the knee and advancing the stripper in a proximal direction.
The 2 tendons are placed side by side and whipstitched together from the center to each end using 2 fiber loop sutures. The patient is then positioned in lateral decubitus on a pegboard with the affected side facing up. The involved arm, as well as the anterior and posterior chest wall, is prepped and draped into the sterile field. The affected arm is secured in a mechanical arm holder (Spyder 2) to allow for intraoperative manipulation and exposure of both the axilla and scapula. The pectoralis muscle is then palpated. The incision should be centered over this and extend from the anterior aspect of the axillary crease at the inferior margin of the pectoralis major and extend proximally toward the coracoid. Dissection is performed through subcutaneous tissue down to fascia overlying the pectoralis major.
The deltopectoral interval is identified, with the cephalic vein serving as a landmark. The pectoralis major tendon is identified inserting at the lateral aspect of the bicipital grove. Subsequently, dissection is performed to separate the interval between the SH and clavicular head. The clavicular head insertion is more superficial and distal to that of the SH. A penrose drain can be used to isolate the SH and provide additional traction during dissection, while a retractor pulls the clavicular head superiorly.
After careful separation, the SH is sharply released off its insertion on the humerus with particular care taken to protect the adjacent biceps tendon. The semitendinosus and gracilis combined graft is placed through the pectoralis major SH using a Pulvertaft weave type of construct.
We then turn our attention to the posterior thorax. The inferior angle of the scapula is palpated and an incision is marked. A perpendicular incision to the long axis of the scapula is made at the level of inferior border of the scapula. The latissimus dorsi muscle fibers are identified superficial to the inferior tip of scapula and split line with its fibers and retracted to expose the teres major origin, which is released off the dorsal surface of the inferior border of the scapula. Subsequently, the ventral surface of the scapula is exposed by subperiosteal dissection of the subscapularis and serratus anterior muscles.
Next, a pineapple burr is used to make a 1-cm circular hole in the inferior aspect of the scapula just proximal to the thickened medial and lateral edges. A malleable or similar retractor is placed between the scapula and chest wall during creation of the hole. Using blunt instrument and digital dissection, a tract is created from the posterior incision, staying just superficial to the chest wall, toward the anterior incision. The tract was dilated using a long hemostat and finger dissection. Subsequently, a long hemostat is used to retrieve the tagging suture and pass the tendon graft construct from the deltopectoral incision to the posterior scapula incision.
The graft is passed through the burr hole in the scapula in a dorsal to ventral direction and looped back upon itself and back through the burr hole a second time.
Interrupted 2-0 Fiberwire sutures are used to secure the tendon to itself and the graft. The tendon is whipstitched to the graft and is wrapped through the tunnel an additional time and tied. Subsequently, the wounds were irrigated and closed with absorbable suture and Dermabond Prineo (Ethicon; Cincinnati, OH).
The dissection is taken from the pectoralis along the chest wall with one finger on the anterior incision and one finger on the posterior incision. It is dilated by finger dissection, and then a long instrument is passed along the chest wall from the anterior incision to the posterior incision, which facilitates passage of the suture and graft.
To avoid complications, abduction and external rotation of the arm can aid in identifying the pectoralis major and defining the interval between the 2 heads of the muscle at a later point in this exposure. Identifying and retracting the biceps tendon during anterior exposure can also help to avoid damage. Creating the soft tissue tunnel for passing the graft from the posterior to anterior position using blunt dissection can ensure the thoracic cavity is not violated and help avoid damage to the neurovascular bundle.
Postoperatively, the patient was placed in an abduction shoulder brace and allowed to perform elbow, hand, and wrist motion only. At follow-up at 10 days, she was provided with a referral to physical therapy for passive range of motion.
At 6 weeks, she was allowed to discontinue sling use and begin active range of motion.
At 6 weeks, the patient was progressed to allow for active range of motion. At 3 months, isometric strengthening was initiated. Finally, at 6 months, the patient was allowed to return to lifting and return to sports.
At 1 year postoperatively, a clinical examination revealed significant improvement in medial scapular winging with 180° painless forward elevation, 70° external rotation, and 18° internal rotation. The patient demonstrated 5/5 strength in all planes of motion and returned to unrestricted activity without pain.
In a case series of 26 patients with EMG-confirmed long thoracic nerve palsy who underwent pectoralis major transfer, they reported improvement of forward elevation from 112° to 149° and external rotation from 53° to 62°. 2 In addition, American Shoulder and Elbow Surgeons scores significantly improved from 28 to 67. Similarly, Warner and Navarro reported on 8 patients who underwent a pectoralis transfer with hamstring augmentation for serratus anterior palsy. At 32-month follow-up, 7 patients had resolution of scapular winging and normal scapulothoracic motion. 3
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Footnotes
Submitted August 11, 2022; accepted October 30, 2022.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
