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Scapulothoracic fusion


OVERVIEW

Chapter synopsis

  • Scapulothoracic fusion is a complex procedure that is used in salvage situations. Indication for this procedure include facioscapulohumeral dystrophy or conditions that lead to periscapular muscle or nerve injury that cause significant winging. Pain and loss of motion are often the driving symptoms for scapulothoracic fusion. Results can be good when the procedure is used in the right patient population.

Important points

  • Scapulothoracic fusion is a salvage procedure.

  • Adequate understanding of the anatomy is key to a successful procedure.

  • Detailed history and physical examination, appropriate imaging, genetic testing, and preoperative planning will help determine whether surgery is indicated.

Clinical and surgical pearls

  • Proper positioning and neuromonitoring is necessary to avoid complications.

  • Take time to release the rhomboids and ensure you are in the space between the serratus anterior and the ribcage.

  • Autograft from the posterior iliac crest is used to help increase the fusion mass and improve fusion rates.

  • Remove interposing tissue and achieve adequate bony contact between the ribs and the scapula for optimal fusion mass.

  • Care should be taken to protect the pleura and avoid pulmonary injury.

  • The authors now use a FiberTape Cerclage (Arthrex, Naples, FL) instead of wire to perform the scapulothoracic fusion.

  • Apply enough tension on the wires to provide adequate compression, but without overtensioning.

  • A custom made postoperative brace is used for the first 6 weeks to aid in fusion. Passive motion begins at 6 weeks and active motion begins at 12 weeks.

Clinical and surgical pitfalls

  • Appropriate patient selection is paramount.

  • Failure to remove sufficient soft tissue can compromise fusion.

  • Aggressive decortication can result in scapular perforation or fracture.

The scapulothoracic articulation is one of four joints, including the glenohumeral, acromioclavicular, and sternoclavicular joints, that work in concert to allow the shoulder to have the greatest range of motion of any joint in the body. Scapulothoracic motion is a significant contributor because it helps account for one third of shoulder elevation. Causes of dysfunction of the scapulothoracic joint can essentially be broken into two categories: dystrophic and nondystrophic. The primary dystrophic cause is facioscapulohumeral dystrophy (FSHD), one of the most common muscular dystrophies after Becker and Duchenne. Nondystrophic causes include peripheral nerve injury, failed tendon transfers for nerve injury, brachial plexus injuries, and stroke. These conditions ultimately alter the stability of the scapular platform and affect glenohumeral motion. This commonly manifests as scapular winging and loss of shoulder motion that leads to pain. Scapulothoracic fusion has been described as a viable salvage operation. , The goal of this procedure is to create a solid union between the anterior surface of the scapula and the posterior thorax to stabilize this articulation, restore some level of function, and alleviate pain.

Preoperative considerations

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