Trapezius-Sparing Approach to Osteochondromas on the Ventral

Home , Rhomboid major muscle, Triangle of auscultation

rst fi with no perioperative xed with a wide bolster fi rmed the tumors to be benign fi en masse Volume 19, Number 3, September 2018 SURGICAL TECHNIQUE exion produced pain. She had preserved external rota- fl ex her shoulder past 80 degrees and further passive fl Our patient underwent magnetic resonance imaging (MRI) of her The appearances were unchanged from MRI imaging preformed This approach utilizes the internervous plane between the The patient was brought to the operating room and placed sacroiliac joint, compared withside. vertebral Painful, body corrugated T8active on clunking scapulothoracic her over motion. contralateral scapula In the dyskinesia the was ribs present.intact range was supraspinatus, Rotator of observed infraspinatus, cuff movement andobserved. examination with teres displayed, revealed Grade minor an 4 withand medical normal the power research belly-press council test wasand power observed. in ipsilateral Impingement tests Gerbers hand, werenormal lift-off negative cervical wrist range of and movementshoulder was range elbow of demonstrated movement and examination and contralateral excision power were of were normal 2 normal. (2 osteochondromasutilizing years A from following the the ventral techniquerevealed surface described an of intact herein). the brachial scapula Neurovascular plexus, examination and normalleft radial and shoulder, ulnar which pulses. measured 16 revealed mm and 2 aroseinferior from ventral the tip ventral of scapular surface the justmore exostoses: proximal scapula, proximal to the and and the the centralsole second to imaging measured this modality 10 (Figs. mmgraph given 1, and and her 2). arose computed history We tomographic of choose examinations MRI HME previously as and conducted. the 1 multiple year radio- previously, with nosymptoms features of she malignancy. Given was theosteochondromas; experiencing, debilitating these a were decision excised wascomplications. The taken patient to wasical remove discharged review at the on 6 postoperative weeksand day and function. 1. 3 Histopathology reports months Clin- con revealedexostoses improvement with in no both evidence pain of chondrosarcomatous transformation. for 3 years withperiod exacerbation before in the symptoms most intensifying recentin over review. a She abduction 3-month reported and mechanical clunking vascular scapular or protraction. She paraneoplastichereditary did multiple symptoms. exostosis not (HME) She report withof previous has osteochondromas any successful around a excisions her neuro- rightosteotomies medical knee, right of history scapula, and both of derotation held proximal in femora. an Ontenderness exaggerated examination, over protective her thesymmetrical posterior arm position, with aspect no was and gross of scapular sheabduct winging. the She had scapula. was or unable widespread Muscle toabduction bulk actively and was tion and extension, but internal rotation was limited to the level of her Patient Setup draped over a bolster.placed The pelvis vertically was onanteriorly the on sacrum the andpreparation, anterior a the superior surgical smaller iliacwith site bolster spine. the was Following placed arm draped skin drapedand free using drape in setup square a are drapes stockinette. illustrated The in Figures patient 3 position and 4. trapezius (accessory nerve) and the latissimus dorsi (thoracodorsal in the lateral position on the operating table with their left arm Incision and Approach 3 10 – ECHNIQUE 3,6 T Excision 6 Techniques in Shoulder & Elbow Surgery rmary Edinburgh Ethics rmary Edinburgh, UK. fi fi Jarrad Stevens, MBBS, FRACS, FAOrthA, 2018 Wolters Kluwer Health, Inc. All rights reserved. In this location they pre- 4,5 r 128) Paul Stirling, BSc (Hons) MBChB (Hons) MRCSEd, – Ventral Surface of the Scapula cant mechanical symptoms, reduced and James T. Patton, FRCS (Tr & Orth), FRCSEd, MB ChB fi cant mechanical symptoms, such a pseudo- fi ict of interest. rmary Edinburgh, UK EH16 4SA fl fi CASE HISTORY 2018;19: 124 Copyright Symptoms from scapular tumors are caused by 1,2 ected from the medial border of the scapula, pre- fl scapula, ventral surface, trapezius, osteochondroma Lesions affecting the ventral surface of the scapula are rare but www.shoulderelbowsurgery.com | A 24-year-old right-hand dominant woman presented to the sar- be associated with signi umors and tumor-like lesions of the scapula are rare and can Committee. Orthopaedics, Royal In (e-mail: [email protected]). Trapezius-sparing Approach to Osteochondromas on the

Tech Should Elb Surg Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. 124 From the Department ofEthical Orthopaedics, approval Royal was In obtained from theThe Royal authors In declare noReprints: con Jarrad Stevens, MBBS, FRACS, FAOrthA, Department of symptomatic osteochondromas. Although no complications were reported bytechniques, the most authors of patients these withwith ventral problems scapular related lesionsprudent to therefore present to scapulothoracic preserve movement. muscleto attachments It where affect possible an seems expeditious andperiod. natural recovery Here in we the postoperative describethe a ventral surface of novel the trapezius-sparing scapula, which approach we to utilize for resection of T Osteochondromas are the most commonscapular benign with neoplasm of an the incidence of 4.6%. Abstract: coma service withinto a her history left hand. of Sheto increasing reported reduced left pain function in shoulder in theextent pain all left shoulder that radiating planes due she ofliving, was scapula including unable self-care. motion. In to This total, use the had her shoulder deteriorated had left to been arm symptomatic the for activities of daily ( can be associatedwinging with or snapping signi scapula syndrome.from Excision this of region osteochondromas can arising beattachments. challenging Access due to to the the numerouswith muscle bony extensive origins muscular surface and detachment of andnovel soft the open tissue scapula dissection. trapezius-sparing may We approach describe be to a associated theKey ventral Words: surface of the scapula. range of movement, snapping scapula syndrome and infrequently, pseudowinging. direct pressure on theinterference adjacent of anatomic joint structures, mechanical range of motion, or by reactive bursitis. detachment and soft tissue dissection.is Although rhomboid typically major re of osteochondromas arising from this region isthe challenging numerous due muscle to origins and attachments. Accesssurface to of the bony the scapula can be associated with extensive muscular associated with pain with reduced range of movement. dominantly present on the ventral surface (63%) and can be vious open techniques approaches have describedtrapezius division of the to safely access the scapulothoracic plane.

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FIGURE 3. Lateral position over elbow bolster.

FIGURE 1. Axial magnetic resonance imaging demonstrating one from the tip of the scapula and along the medial scapula border of the osteochondromas. The arrow shows the ventral surface superiorly a length of 4 cm (Fig. 7). This incision provided a osteochondromas on the scapula. cuff of tissue amenable to repair on closure. At this point a bone hook was placed on the tip of the scapula, which was elevated nerve). A 10 cm oblique longitudinal incision was performed by the surgeon’s assistant (Fig. 8). A self-retainer placed in the perpendicular to the medial border of the scapula (Figs. 4, 5) reflected fibers of rhomboid major allowed for clear visual- traversing the triangle of auscultation. The triangle of auscultation ization of the ventral surface of the scapula (Fig. 9). A long is depicted in the lithograph by Quain and highlighted in red ring-handled spike was gently placed into the scapulothoracic (Fig. 5) titled plate 22. The borders of the triangle are as follows: plane and held in line with the lateral border of the scapula to the medial border is defined by the lateral edge of trapezius, the protect the lateral structures. Both osteochondromas were then lateral border is defined by the vertebral border of the scapula and removed using an osteotome, which was placed in the plane the inferior border of the triangle is defined by superior edge of between the subscapular fossa and subscapularis (Fig. 10). latisimus dorsi.12 The scapular attachment of rhomboid major Hemostasis was achieved, rhomboid major cuff repaired with a defines the floor of the triangle. Following superficial sharp dis- braided absorbable suture, followed by fascial closure and section, electrocautery was used to continue the incision through monofilament absorbable suture to the subcuticular layer. superficial fat until the deep fascia was encountered. At this point, The osteochondromas where inspected and no unusual a self-retaining retractor was inserted into the skin edges (Fig. 6). features where identified. The specimens were sent for histol- The lateral edge of the inferior fibers of the trapezius can ogy (Figs. 11, 12). be identified and retracted medially. In a similar manor the horizontal muscle fibers of latisimus dorsi are identified and Postoperative Regime and Patient Outcome retracted inferiorly thereby enlarging the auscultatory triangle. The patient initially rested in a sling for 48 hours for Attention was now turned to the rhomboid major muscle. comfort. An early full range of comfortable passive movement fl The con uent fascia and tendinous attachments of this muscle was allowed. Formal physiotherapy was initiated at 2 weeks fl onto the medial border of the scapula were incised and re ected with assisted forward elevation, abduction, and rotation. Active full range of movement was commenced at 6 weeks postoperation with isometric strengthening commenced 2 weeks after. At 3-month postoperation our patient has described her

FIGURE 2. Sagittal magnetic resonance imaging demonstrating the second osteochondroma. The arrow shows the ventral FIGURE 4. Scapula outlined and incision placement indicated surface osteochondromas on the scapula. dotted line.

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FIGURE 7. Rhomboid major (RMa) is detached from the scapula. Infraspinatus (IS) is visualized.

by meticulous subperiosteal elevation, leaving the muscles substance of rhomboid major intact. If significant bleeding is FIGURE 5. Plate 22 lithograph detailing relationship of the encountered, ligation of effected vessels can be undertaken due 13 muscles and bone which form the auscultatory triangle. Triangle to the well-developed anastomosis around the scapular tip. highlighted in red. Incision dotted line.11 Major Nerves shoulder as functioning normally with a recorded range of This technique utilizes a true internervous plane between movement: forward flexion 180 degrees, backward extension the latissimus dorsi and the trapezius. The dorsal scapular nerve 30 degrees, external rotation 90 degrees, internal rotation 60 runs through the substance of the rhomboid major and, like the degrees, abduction 150 degrees, and rotator cuff power grade 5 artery, could potentially be injured while reflecting rhomboid and symmetrical with right side. major from its scapula origin. Careful blunt dissection is uti- lized at the inferomost aspect of the rhomboid major to mini- Risks of the Approach mize this risk. There are 3 branches of the posterior cord of the brachial plexus that run through the scapulothoracic plane: the Major Blood Vessels superior and inferior subscapular nerves, which provide motor The scapula receives its arterial supply from an anasto- innervation to subscapularis, and the thoracodorsal nerve, motic ring formed from the circumflex scapular artery and which provides motor innervation to the latissimus dorsi. These thoracodorsal arteries (branches of the subscapular artery), and nerves run in a plane between the subscapularis and the thoracic the dorsal scapular artery (terminal branch of the deep trans- wall and they should not be encountered in this approach verse cervical artery). The thoracodorsal artery runs along the provided the subscapularis muscle is not perforated by the inferolateral border of the scapula, with branches to the infra- osteotome when working on the ventral bone of the scapula. spinous fossa, and it is not encountered in this approach. The dorsal scapular artery runs down the medial border of the scapula in the substance of the rhomboid major. This vessel was DISCUSSION not encountered during this approach. Foreseeably, branches of Solitary osteochondromas are commonly encountered in fl this vessel may be encountered, although the risk of significant the long bones and less frequently observed in the at bones damage is minimized by incision into the confluent fascia and tendinous portion of the insertion of rhomboid major, followed

FIGURE 6. Superficial dissection traversing the triangle of FIGURE 8. The scapula can be retracted allowing access to auscultation. subscapularis.

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FIGURE 9. Visualization of the osteochondromas. such as the scapular.14 Even though they are encountered less FIGURE 11. First osteochondroma excised from scapula. frequently in this bone, osteochondromas are the most common benign neoplasm of the scapular with an incidence of 4.6%.4,5 Kwon and Kelly8 describe a parascapular skin incision In this location they predominantly present on the ventral sur- along the medial border of the left scapula with 5 cm of the face (63%).6 Although the incidence of osteochondroma on the trapezius muscle being divided at the medial scapular border in ventral surface of the scapula has been published, an association the line of the skin incision. Fageir et al9 also describe a par- in correlation of symptoms is limited to case reports and case ascapular skin incision along the medial border of the left series. Chondrosarcomatous transformation occurs in 1% of scapula with 5 cm of the trapezius muscle being divided at the solitary osteochondromas, and in up to 27% of patients with medial scapular border in the line of the skin incision. Esenkaya HME, with scapular osteochondromas recognized as having the reported a parascapular incision parallel to the vertebral and highest risk of malignant transformation of all anatomic sites.14 superior border of the scapula. The trapezius and the rhom- For these reasons, surgical excision is often advised.15 boideus muscles were sectioned in dieir mid substance to access The authors are aware of 7 other papers describing tech- the scapula.7 Tungdim et al10 described a 5 cm incision which niques for resection of tumors on the ventral surface of the was parallel to the lower half of the medial border of the scapula. Perez et al16 and Fukunaga et al17 describe minimally scapula with trapezius incised along the skin incision. Nerces- invasive resection of ventral osteochondromas using a thor- sian and Denton reported an approach with a parascapular acoscope with no immediate complications. Perez and col- incision made between the spinous processes and the medial leagues undertook laceration of the serratus anterior, trapezius, border of the scapula. In this approach the trapezius and the and rhomboid major to place port sites and gain arthroscopic rhomboid major muscles were divided and retracted.13 access, whereas Fukunaga and colleagues approached the The previous techniques described incision of the trapezius ventral surface from the lateral border of the scapula, detaching in its inferolateral substance to further gain access to the medial the tendon of teres major in the process. Kwon and Kelly,8 border of the scapula. This is followed by reﬂection of the Fageir et al,9 Esenkaya,7 Tungdim et al10 and Nercessian and rhomboid major muscle from the medial border of the scapula. Denton3 reported single cases of open excision of ventral The trapezius-sparing technique is made possible by the scapular osteochondromas. Comparison of these reports with skin incision made perpendicular to the medial border of the our technique is presented in Table 1.

FIGURE 10. Removal of osteochondromas with osteotome. FIGURE 12. Second osteochondroma excised from scapula.

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TABLE 1. Comparison of Published Surgical Techniques References Techniques Muscles Detached or Incised In the study Open, incision perpendicular to medial border of scapula, trapezius-sparing Rhomboid major Tungdim et al10 Open, medial parascapular approach, trapezius-incising Trapezius and rhomboid major Fageir et al9 Trapezius-detaching Trapezius and rhomboid major Kwon and Kelly8 Open, medial parascapular approach, trapezius-incising Trapezius and rhomboid major Perez et al16 Thoracoscopic Serratus anterior, rhomboid major, trapezius Fukunaga et al17 Thoracoscopic Teres major Esenkaya7 Open, medial parascapular approach, trapezius-incising Trapezius and rhomboid major Nercessian and Denton3 Open, medial parascapular approach, trapezius-incising Trapezius and rhomboid major scapula centered on the triangle of auscultation. This triangle is REFERENCES manipulated with retractors to give increased working space 1. Danielsson LG, el-Haddad I. 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Muscles of the Human Body in a Series of Plates (Plate 22). extending the approach would involve incision of the trapezius London: Taylor & Walton; 1836. muscle. The senior author (J.T.P.) has not found this to be necessary to date. We were able to identify and excise 2 12. Last RJ. Anatomy regional and applied J & A Churchill London. 1954 osteochondromas from the ventral surface of the scapula, 1 (p. 71). being on the medial border and 1 more central. Being that the 13. Seneviratne S, Duong C, Taylor IG. The angular branch of scapula is a large flat bone, safe exploration and excision of the thoracodorsal artery and its blood supply to the inferior angle of tumors and tumor-like lesions may require different approaches, the scapula: an anatomical study. Plast Reconstr Surg.1999;104: especially if they occur superiorly or laterally. 85–88. 14. Clement ND, Ng CE, Porter DE. Shoulder exostoses in hereditary CONCLUSIONS multiple exostoses: probability of surgery and malignant change. – This is the first description of an open trapezius-sparing J Shoulder Elbow Surg. 2011;20:290 294. approach to the ventral surface of the scapula. Our technique is 15. Garrison RC, Unni KK, McLeod RA, et al. Chondrosarcoma arising in safe, effective, allows early rehabilitation postoperatively, and osteochondroma. Cancer. 1982;49:1890–1897. respects the principles of tumor surgery for this presentation. 16. Perez D, Ramón Cano J, Caballero J, et al. Minimally-invasive resection of a scapular osteochondroma. Interact Cardiovasc Thorac Surg. ACKNOWLEDGMENTS 2011;13:468–470. The authors gratefully acknowledge the Royal College of 17. Fukunaga S, Futani H, Yoshiya S. Endoscopically assisted resection of Surgeons Edinburgh Library for access to first edition ana- a scapular osteochondroma causing snapping scapula syndrome. World tomic illustrations. J Surg Oncol. 2007;5:37.