Evolving Technique: Resect the Superomedial Angle

John E. Kuhn, MD, MS Kenneth D. Schermerhorn Professor of Orthopaedics Chief of Shoulder Surgery Vanderbilt University Medical Center

V A N D E R B I L T S P O R T S M E D I C I N E Snapping Scapula

• Snapping may not be pathologic • Snapping may lead to bursitis which is symptomatic • “sound about the room without the slightest pain”

V A N D E R B I L T S P O R T S M E D I C I N E IMPORTANT POINTS

• Crepitus May NOT be Symptomatic • Crepitus and Bursitis MAY BE Related • Treatment – Nonoperative – Arthroscopic – Open Surgery

V A N D E R B I L T S P O R T S M E D I C I N E Snapping Scapula

• Degrees (Mauclaire 1904) – Froissement-physiologic – Frottemont-louder grating sometimes pathologic – Craquemont-always pathologic

V A N D E R B I L T S P O R T S M E D I C I N E Causes of Snapping Scapula • Bone • Soft Tissue – Osteochondroma (Scapula and Rib) – Bursitis – Fracture (Scapula and Rib) – Tuberculosis – Hooked Superomedial Angle – Syphylitic – Luschka’s Tubercle • Muscle – Reactive Spurs-Muscle Avulsion – Atrophy • Congruence – Fibrosis – Scoliosis – Anatomic Variants – Kyphosis – Postural V A N D E R B I L T S P O R T S M E D I C I N E Luschka’s Tubercle

V A N D E R B I L T S P O R T S M E D I C I N E Bursal Anatomy • Natural Bursae • Adventitial Bursae

V A N D E R B I L T S P O R T S M E D I C I N E Scapulothoracic Bursitis • History of Overuse • Swelling/Pain along Medial Border • May have Subtle Winging • May have Crepitus

V A N D E R B I L T S P O R T S M E D I C I N E Inferior Angle Bursitis in Throwers • Rare • Swelling/Pain in Cocking • May Require Surgical Excision

V A N D E R B I L T S P O R T S M E D I C I N E Clinical Assessment • History – Pain • Location • Aggravating Features – Popping • Physical Exam – Scapula Exam – Demonstrate Snapping?

V A N D E R B I L T S P O R T S M E D I C I N E Clinical Assessment Inferior Angle Bursitis

V A N D E R B I L T S P O R T S M E D I C I N E Snapping Scapula

V A N D E R B I L T S P O R T S M E D I C I N E Nonoperative Treatment

• Postural Correction – Figure of 8 brace • Subscapularis/Serratus Muscle Strengthening • Injections into Bursa – Watch for Pneumothorax • Coaching

V A N D E R B I L T S P O R T S M E D I C I N E Surgical Treatment of Scapular Bursitis and Snapping Scapula

• ARTHROSCOPIC • OPEN

V A N D E R B I L T S P O R T S M E D I C I N E Arthroscopic Treatment

• Mark Landmarks

V A N D E R B I L T S P O R T S M E D I C I N E Portal Placement

Avoid Neurovascular Structures

V A N D E R B I L T S P O R T S M E D I C I N E Inject the Bursa

V A N D E R B I L T S P O R T S M E D I C I N E Insert Scope Blunt Tools

V A N D E R B I L T S P O R T S M E D I C I N E Views

NOT IN BURSA IN THE BURSA

V A N D E R B I L T S P O R T S M E D I C I N E Osteochondroma

V A N D E R B I L T S P O R T S M E D I C I N E Open Surgery Resection of the Superomedial Angle

V A N D E R B I L T S P O R T S M E D I C I N E Subperiosteal Resection

• Window through Trapezius • Elevate Supraspinatus • Shell out SM Angle and Remove V A N D E R B I L T S P O R T S M E D I C I N E V A N D E R B I L T S P O R T S M E D I C I N E V A N D E R B I L T S P O R T S M E D I C I N E V A N D E R B I L T S P O R T S M E D I C I N E Surgical Treatment • Resect Abnormal Bone • Resect Bursa • Superomedial Angle Resection

V A N D E R B I L T S P O R T S M E D I C I N E Results of Surgery • All Case Series • 85-90% success • Allow return to unrestricted activity • PEARLS: – Shell Out the Bone in a Subperiosteal Plane – Meticulous Repair of Muscle Plane – Repair to Bone When Possible

V A N D E R B I L T S P O R T S M E D I C I N E Summary

• Scapulothoracic Crepitus is NOT Uncommon • It may be ASYMPTOMATIC-Watch for Secondary Gain! • Crepitus and Bursitis May Occur together or May be Independent • Nonoperative Treatment is an Option • Surgery, If Required is usually successful

V A N D E R B I L T S P O R T S M E D I C I N E Thank You

V A N D E R B I L T S P O R T S M E D I C I N E