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

Abstract

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.

Keywords: Scapulothoracic tenodesis; facioscapulohumeral muscular dystrophy; hamstring graft; scapula winging; scapulothoracic arthrodesis.

Figure 1.

Patient positioning & surface markings: (a) lateral patient position maintaining in-line cervico-thoracic vertebral coronal alignment & positioning of ipsilateral arm on gutter support; (b) marked spinous process of vertebrae & medial scapula border (blue lines) ensuring medial-scapula-vertebral angle of 20°; (c) skin incision (red line).

Figure 2.

Superficial dissection: rhomboids (yellow dotted line) & medial border of scapula (green line).

Figure 3.

Superficial dissection: rhomboids reflected medially identifying dorsal scapula nerve (green arrows).

Figure 4.

Deep dissection: 5th–8th posterior ribs identified following medially retracted paravertebral muscle (cleared of periosteum with rib-stripper).

Figure 5.

Illustration demonstrating stepwise approach to stripping rib & protecting neurovascular bundle.

Figure 6.

Illustration demonstrating positioning of 1/3 tubular plate & tendon grafts for tenodesis & of rhomboid sutures during closure.

Figure 7.

Tendon grafts tied around 5th–8th ribs.

Figure 8.

Tendon grafts passed through drill holes and tied around medial scapula & plate.

Figure 9.

Clinical photograph of patient with FSHD 18 months following left ST demonstrating stable scapula: (A) in neutral; (B) external rotation; (C) forward flexion; (D) abduction.

Figure 10.

(A) Pre-operative & (B) post-operative radiographs of patient with left ST demonstrating 8-hole 1/3 tubular plate utilised as ‘washer’.