Abstract
Surgical Technique
Step 1: Preoperative Workup
Step 2: Patient Positioning

Step 3: Pectoralis Major Harvest



Step 4: Scapula Exposure

Step 5: Preparation for Tendon Transfer and Allograft Augmentation

Step 6: Scapula Tunnel Preparation and Tendon Transfer



Step 7: Postoperative Rehabilitation
Discussion
Operative Step | Pearl | Pitfall | Solution |
---|---|---|---|
Step 1: Preoperative workup | The surgeon should manually stabilize the scapula during active forward elevation and determine whether typical pain complaints are relieved and function is improved, which would confirm winging as the primary pathology. | Failure to diagnose primary shoulder or neck pathology as a cause of scapular winging can occur. | The initial workup should include plain radiographs of the chest, cervical spine, shoulder, and scapula. Physical examination should assess for shoulder instability or symptomatic labral tearing. |
Step 2: Patient positioning | A pneumatic limb positioner centered over the proximal third of the operating room table allows dual access to the anterior and posterior aspects of the shoulder for the 2-incision technique. | Inadequate intraoperative access to the medial border of scapula can occur. | Wide draping should be performed with nonsterile adhesive barriers, and sterile drapes should be taken to the midline spine posteriorly. |
Step 3: Pectoralis major harvest | Correct identification of the raphe between the sternal and clavicular heads is important to prevent muscular injury, which can cause poor excursion and denervation. | A truncated pectoralis major musculotendinous harvest can occur. | The surgeon should create wide subcutaneous flaps to optimize visualization in the operative field and should retract the more superficial clavicular head proximally to identify the most lateral insertion point of the sternal head tendon. |
Step 4: Scapula exposure | The surgeon should digitally dissect the axillary channel simultaneously from anterior and posterior for proprioceptive guidance and avoidance of divergent paths. | Neurovascular injury can occur within the axillary tunnel. | Dissection should be performed carefully along the chest wall within the distal extent of the axillary wound to ensure the transferred pectoralis major structure does not compress or impinge on the brachial plexus. |
Step 5: Preparation for tendon transfer and allograft augmentation | The surgeon should measure the length-to-transfer distance before deciding to augment with a graft. In many cases a direct transfer is achievable after adequate pectoralis mobilization. | A poorly secured graft to a shortened pectoralis major tendon is possible. | Use of the Pulvertaft weave technique through a portion of the pectoralis muscle extends the working length of the tendon and secures graft incorporation. |
Step 6: Scapula tunnel preparation and tendon transfer | A point-to-point clamp should be used through the scapula body with a strong pull laterally to assist in delivering the scapula into the operative wound for tunnel drilling. | Fracture of the inferior pole of the scapula can occur. | The surgeon should mark the site for the tenodesis hole at least 1 cm proximal to the inferior edge and 1 cm medial to the lateral cortical edge to avoid blowout. |
Step 7: Postoperative rehabilitation | Rehabilitation should progress slowly. Particularly with the indirect transfer method, there is a risk of graft elongation and failure. | Prolonged immobilization, leading to stiffness and secondary scapular dyskinesis or recurrent winging, is possible. | Proper balance between protection and immobilization is important. A team approach to rehabilitation is critical. Good communication with the therapist is needed. Manual scapular stabilization should be performed during overhead stretching. |
Advantages |
Dynamic solution for dynamic problem |
Optimizes range of motion |
Added length from graft allows tension-free muscle transfer |
Relatively low perioperative morbidity and complication rate compared with scapulothoracic fusion |
Disadvantages |
Inadequate treatment for dystrophic causes of scapular winging |
Risk of recurrence particularly in young laborers and overhead athletes |
Attenuation of graft over time can lead to recurrence |
May cause unacceptable cosmetic deformity of chest |
Supplementary Data
- Video 1
The patient is placed in the lazy left lateral decubitus position with the assistance of a pneumatic arm positioner for simultaneous access to the pectoralis major and scapula. The sternal head of the pectoralis major is identified and harvested within the deltopectoral interval. After exposure of the anterior and posterior aspects of the inferior angle of the scapula, an axillary submuscular tunnel is created to connect the anterior and posterior wounds. The length-to-transfer distance for the sternal head is then determined. If additional length is needed, a semitendinosus allograft is incorporated into the sternal head musculotendinous unit. With care taken to preserve an intact bony bridge, a transosseous tunnel is drilled over the inferolateral scapula. The pectoralis major sternal head and graft are then passed from anterior to posterior, and the graft is sutured back onto itself for the indirect transfer. The inferior angle of the scapula is pushed against the chest wall and as far laterally as possible to properly position the scapula before final graft fixation.
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The authors report the following potential conflict of interest or source of funding: W.S.C. receives support from Arthrex, DePuy, Mitek. A.K. receives support from Arthrex, DePuy, Mitek. J.M.T. receives support from Arthrex, DePuy, Mitek. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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