Leigh Ann Curl, MD Harborview Sportsmedicine and Shoulder ...
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Scapular Fixation Surgery
Leigh Ann Curl, MD
Harborview Sportsmedicine and Shoulder Surgery
Medstar SportsHealth
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Shoulder Joint
• Greatest range of motion of all the joints
in the body
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Basic Anatomy
• Scapula (shoulder blade)
• Humerus (upper arm)
• Clavicle (collar bone)
• Ribs
• Muscles
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Muscles
• Many different muscles
– Some primarily act across the ball and socket joint
– Some primarily act across the rib cage and
scapula
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Shoulder Motion
• Normal shoulder
motion results from the
combined motion of the ball and socket joint
AND the shoulder
blade moving relative
to the rib cage
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Shoulder Motion
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FSHD
• Primarily involves the muscles
responsible for control of the scapula
– Rhomboids
– Serratus anterior
– Trapezius
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FSHD
• Loss of scapular muscle control
– difficulty achieving overhead positions
• Weakness, fatigue
• Motion commonly less than shoulder height
– scapular winging
• Present at rest – discomfort against firm
surfaces
• Becomes more pronounced with attempted motion
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FSHD
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FSHD
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Scapular Fixation
• Scapulothoracic fusion
– fusion of the scapula to the underlying ribs
– Fixes the scapula into a stable position
• Creates a “stable platform” for the intact ball and socket muscles to function
– Ease of achieving overhead positions
– Less fatigue
– Winging impossible
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Surgical Candidates
• No significant medical
concerns
• Poor shoulder function with
desire to be better
• Involvement limited to the
scapula muscles
– normal rotator cuff and deltoid
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Surgical Candidates
• Response to manual compression test
• Willingness to undergo the surgery and comply with post-operative restrictions
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Surgical Procedure
• General anesthesia (“fully asleep”)
• Face down
• Fully monitored
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Surgical Procedure
• Incision along medial border of scapula
– Expose inner margin of the scapula bone along its full length
– Expose adjacent underlying rib levels
• 3 to 5 ribs used
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Surgical Procedure
• Wire scapula to the adjacent ribs
– some surgeons use other techniques
• Bone graft the contact points
– Hip bone (iliac crest) – probably best
– Off –the- shelf products
– +/- implantable bone stimulator to
promote fusion (battery powered)
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Surgical Procedure
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Surgical Procedure
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Surgical Procedure
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Surgical procedure
• Typically 3 to 4 hours
• 1 to 2 units of blood loss
– very rare to need a transfusion
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Hospital Stay
• 3 to 5 days on average
– 24 hours IV antibiotics
– pain management -- significant
• Operated arm protected in a sling at all
times
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Possible Acute Complications
• Anesthesia
• Infection -- rare
• Neurologic -- rare
• Lung
– Puncture (pneumothorax)
• Chest tube
– Blood (hemothorax)
– Sense of shortness of breath
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Rehab Protocol
• First 6 weeks
– Sling – NO USE of extremity
– Elbow, wrist, hand motion to avoid stiffness
– May do some limited passive motion
across shoulder
• dangling activity
• restricted pool activities
• therapist
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Rehab Protocol• Weeks 7 to 12
– Expect some early bone healing
– Wean from sling
– Progress passive motion
– begin gentle active – assisted motion
• Motion in water/pool (aquatic therapy)
– Minimal muscle work
• Limited to isometrics
– May feed, dress, light desk-work
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Rehab Protocol
• Weeks 12 to 18
– Expect good bone-bone healing
– Full active motion
– May increase day to day functions
– Limit weight to 5 to 7 pounds
• Waist to shoulder activities
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Rehab Protocol
• Weeks 19 and on
– Expect solid fusion
– increase activities to tolerance
– May do gentle strengthening or resistance activities
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Results
• Improvement in shoulder function by six
months, but can continue to improve up
to one year from surgery
– average about 60 to 65 degrees of improvement forward (flexion) and to the side (abduction)
– Typically achieve aproximately 145 degrees of forward elevation and abduction
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Results
• Resolution of winging
• Improved shoulder contour & motion
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Results
• Failure to heal (“nonunion”)
– uncommon
• Smoking
• Not compliant with post-op restrictions
• Bilateral procedure (not reccomended)
• Stiff shoulder
– usually responds to therapy
– prevention is key
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Results
• Painful wires
– Occasionally need to remove wires (< 10%)
• Deterioration of function
– May lose motion if deltoid or cuff become involved over time, but other advantages remain
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THANK YOU