A Basic Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam. Inspection for scapular winging (lateral or medial) Evaluate the strength of trapezius, rhomboids, and serratus anterior Assess shoulder forward flexion with and without scapular stabilization 2 Orders and interprets required diagnostic studies EMG studies can be helpful to assess function of serrates anterior, trapezius, and rhomboid 3 Prescribes and manages nonoperative treatment. Physical therapy to focus on serratus and periscapular muscle strengthening. Prolonged course of conservative management recommended given the time required for nerve palsies, if present, to resolve 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management documents duration of nonoperative managment documents appropriate indications for scapulothoracic fusion: patient is not a candidate for a soft tissue procedure (split pectoralis transfer, triple tendon transfer) or has failed prior soft tissue procedure C Preoperative H & P 1 Perform basic H&P Documents pertinent medical co-morbidities (i.e lung/heart/renal pathology) Documents pertinent medications (i.e blood thinners) Documents presence of scapular winging, periscapular muscle strength, and full neurological examination 2 Perform operative consent describe complications of surgery including Pneumothorax Hemothorax Nonunion Persistent winging
F Room Preparation 1 Consultant notification CT surgery should be notified prior to the case in the event of a pleural injury requiring a chest tube 2 Surgical Instrumentation 18g wire Small frag instrument set Cancellous bone chip allograft Plate benders and wire cutters Penfield dissectors Burr 3 Room setup and Equipment Jackson frame table No fluoroscopy required 4 Patient Positioning Prone position Both scapulas in their entirety should be prepped (medial to lateral) C4 down to the iliac crests should be prepped (cephalad to caudal) in the event iliac crest autograft harvesting is required The C7 spinous process is an important anatomic landmark that can be used to guide counting ribs The entire ipsilateral upper extremity should be prepped as manipulation of the arm is required intraop for adequate exposure G Superficial Dissection 1 Identify landmarks and draw incision. C7 spinous process Vertebral border of the scapula Scapular spine T1-T7 Spinous process 2 Step 1 of superficial dissection Dissect down to trapezial fascia 3 Step 2 of superficial dissection The trapezius is isolated and released off the lateral scapula H Deep Dissection 1 Step 1 of deep dissection The trapezius is reflected medially after its release The rhomboid major is isolated medially and released laterally off the vertebral border of the scapula 2 Step 2 of deep dissection The arm is then internally rotated and placed on the lower back to expose the anterior surface of the scapula The serratus anterior is identified (may be atrophic) and its medial 1/3rd is resected. The medial 1/3rd of the subscapularis is also resected directly off the scapula medially. This allows for bone on bone contact between the scapula and the ribs for arthrodesis Next, 2-3 cm of infraspinatous muscle belly is elevated off the posterior surface of the scapula in a medial to lateral direction This allows space for placement of a small frag plate I Therapeutic Skill 1 Step 1 of basic therapeutic skill (soft tissue) At this point, ribs 3-6 +/-7 should be exposed The C7 spinous process superficially and palpation of the 1st rib can assist in identification of the correct ribs Perform a trial reduction aligning the spine of the scapula with the 4th rib posteriorly The posterior aspects of ribs 3-6 are decorticated by a burr 2 Step 2 of basic therapeutic skill (soft tissue) A series of 8-10 holes should then be made through the scapular body (inferior to the scapular spine) in the location where the infraspinatus was elevated. The space between each hole should correspond to the space between holes in the small fragment plate which align with the superior and inferior aspects of the stabilizing rib to be used. J Therapeutic Skill 1 Step 1 of advanced therapeutic skill (soft tissue) Very carefully and meticulously, a Penfield #1 dissector is used to separate the anterior aspect of the posterior ribs from the posterior pleura The Penfield 1 must be traversed from an inferior to the superior direction to avoid iatrogenic injury to the intercostal neurovascular bundle K Therapeutic Skill 1 Step 1 advanced therapeutic step (instrumentation) 18g wires loops are passed in an inferior to superior direction around ribs 3-7 one by one The exposed wound is then filled with a liter of saline and a Valsalva maneuver at 30 mmHg should be conducted by anesthesia The absence of any bubbles during the Valsalva maneuver is generally predictive of absence of pleural injury 2 Step 2 of advanced therapeutic skill (instrumentation) Folded over 18g wires are then passed through the holes in the scapula (one wire per rib) A pre-contoured plate is then placed over the dorsal scapula and the 18g are passed through the plate. A 22-gauge blunt-tipped needle is then utilized to place an intercostal block at the second through sixth interspaces (~5 cc in each interspace) L Therapeutic Skill 1 Step 1 of intermediate therapeutic skill (instrumentation) Cancellous bone graft (120 cc) is mixed with vancomycin powder and placed in the space between the ribs and anterior surface of the scapula. Iliac crest autograft can also be harvested and used for bone grafting 2 Step 2 of intermediate therapeutic skill (instrumentation) A reduction is performed to bring the scapula down and touch the ribs, (with the arm in 90 degrees of abduction), aligning the spine of the scapula with the 4th rib With the scapula and ribs touching each other, the wires are then secured to one other to hold the scapula down. N Wound Closure 1 irrigation, hemostasis, and drain A drain is placed deep to the trapezius (superficial to the rhomboids) 2 deep closure The rhomboids are then repaired back to the vertebral border of the scapula The trapezius is repaired back to its release off the lateral scapula 3 superficial closure The subcutaneous tissue and skin are then closed in standard fashion 4 dressing and immediate immobilization Sterile dressings applied A shoulder immobilizer sling is then placed