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Home , Lateral pectoral nerve, Pectoralis major, Serratus anterior muscle, Trapezius

Chapter 46 Transfer for Scapular Winging Andreas H. Gomoll, MD Brian J. Cole, MD, MBA

■ Indications before traveling along the lateral as- ■ Contraindications pect of the . The superficial lo- Scapular dysfunction is a relatively cation makes it susceptible to blunt Associated paralysis of the common orthopaedic problem, result- trauma, but other etiologies exist such muscle is a relative contraindication ing from a variety of conditions that as traction injuries, because it compromises the results of includes deconditioning and primary neuritis (Parsonage-Turner syn- pectoralis major transfer. If present, pathology. In most patients, drome), and iatrogenic injuries. Most trapezius palsy should be addressed rehabilitation leads to a resolution of traumatic insults to the long thoracic by a levator and rhomboid symptoms. Occasionally, scapular are blunt injuries from sports transfer, preferably in a staged proce- winging (Figure 1) is refractory to participation or accidents that result dure. Previous injury or compromise nonsurgical treatment. In most of in a neurapraxia, but repetitive stren- of the pectoralis major musculotendi- these patients, scapular winging re- uous activities also have been impli- nous unit also is a contraindication to sults from serratus anterior dysfunc- cated. this procedure as it interferes with the tion and may be a source of consider- palsy usu- ability to transfer the tendon able functional limitations and , ally resolves within 8 to 12 months appropriately. especially with overhead activities or but can last up to 2 years in infectious ■ when the is positioned away from etiologies. However, up to 25% of pa- the body. The serratus anterior stabi- tients experience persistent scapular lizes the scapula to the chest wall dur- winging and fatigue. Initial treatment Alternative ing elevation and is the most powerful ■ should consist of gentle range-of-mo- Treatments protractor of the . The most tion exercises to avoid shoulder stiff- frequently reported complaints are ness. Electrodiagnostic studies can be weakness of elevation, fatigue with obtained at 3-month intervals to eval- Continued physical therapy,the use of overhead activities, and posterior uate recovery of the nerve. If physical a brace to stabilize the scapula against periscapular pain. Because these examination or electrodiagnostic the chest wall, and avoiding overhead symptoms are frequently vague and activities are valid nonsurgical treat- studies do not demonstrate signs of nonspecific, delayed or incorrect diag- ment modalities. Many patients, how- recovery after a year, surgical treat- noses such as glenohumeral instabil- ever, are unable to tolerate indefinite ment may be indicated. The procedure ity or subacromial impingement are brace use and functional limitations, of choice for persistent scapular injury common. and they choose surgical treatment. The long thoracic nerve supplies secondary to long thoracic nerve pal- Many techniques have been described the and is sy/serratus anterior weakness is trans- to address scapular winging, and all formed from the anterior rami of C5 to fer of the pectoralis major tendon to aim to statically or functionally stabi- C7; its injury causes weakness or com- the scapula. lize the scapula. Scapulothoracic fu- plete paralysis. The roots of C5 and C6 sion achieves static stabilization ■ run through the middle scalene mus- through fixation of the scapula to the cle, then merge with fibers from C7, chest wall. Fusion is successful in ad-

American Academy of Orthopaedic Surgeons 439 Management of Neurologic Deficits/Muscle Weakness

Traditional techniques have used a long anterior incision in the deltopectoral interval, but many sur- geons, ourselves including, prefer two smaller incisions to provide improved cosmesis. The anterior incision mea- sures approximately 3 to 4 cm, and is centered in the inferior half of the ax- illary crease (Figure 2, A ). It begins at the inferior margin of the pectoralis major tendon and extends proximally, ending just lateral to the coracoid. A posterior incision of similar length is Figure 1 Scapular located over the inferior and lateral winging as evident border of the scapula (Figure 2, B). with attempted ele- vation of the upper extremity. Instruments/Equipment/Implants Required dressing scapular winging, but it elim- tact with the scapula and use the graft Allograft tendon, if preferred over au- inates scapulothoracic motion. On av- only to reinforce the repair. Overall, togenous hamstring graft, should be erage, one third of total elevation is transfer of the sternal head of the pec- ordered in advance. A long hemostat lost after arthrodesis, as is a significant toralis major tendon is a successful or Kelly clamp facilitates passage of amount of extension and external ro- procedure to address painful scapular the traction sutures. A 7-mm drill or tation. Nonunion rates of up to 50% winging refractory to nonsurgical reamer is used to create the scapular also have been described. Thus, management, providing consistent drill hole for graft fixation. scapulothoracic fusion should be re- functional improvement and pain re- served for cases of systemic muscular lief through dynamic stabilization Procedure weakness, such as muscular dystro- (Table 1). PECTORALIS TENDON HARVEST phies, or as a salvage procedure in pa- ■ Following the skin incision, an elec- tients with intractable pain and dys- trocautery device is used for dissec- function after muscle transfer. tion through the subcutaneous fat to ■ ■ Techniques the overlying the pectoralis ten- don. The creation of subcutaneous Setup/Exposure flaps should be avoided to prevent ■ Results A combination of regional inter- postoperative hematoma formation. scalene block with general The pectoralis major tendon inserts Traditionally, failure rates for pectora- reduces postoperative pain and de- on the just lateral to the long lis major transfer have ranged be- creases narcotic requirements in the head of the biceps tendon and consists tween 0% and 26%. Early techniques early postoperative period. The pa- of the deeper sternal head that inserts were associated with significant donor tient is positioned on a standard oper- on the lateral lip of the bicipital site morbidity from the fascia lata graft ating table with the help of a pneu- groove, and the superficial clavicular harvest, but this problem has been matic (bean) bag in the lateral head that inserts more laterally. The successfully addressed by the use of decubitus position with the torso raphe between the clavicular and ster- autograft or allograft hamstring ten- tilted 30° posteriorly. This position al- nal head is identified most easily ap- don. Earlier studies also described lows the surgeon to simultaneously proximately 7 to 9 cm medial to its failures resulting from stretching of access the sternal head of the pectora- insertion (Figure 3). The overlying the avascular fascia lata graft when lis major tendon and the inferior pole fascia is incised and bluntly dissected used to extend the length of the pec- of the scapula. The shoulder is draped to develop the interval between the toralis major tendon. This issue also free to the midline both anteriorly and sternal and clavicular heads. Abduc- has been resolved as contemporary posteriorly.It is critical that the medial tion and external rotation of the arm techniques attempt to approximate border of the scapula is easily palpable are helpful to define the interval and the pectoralis tendon into direct con- to allow intraoperative manipulation. to improve exposure. The deeper ster-

440 American Academy of Orthopaedic Surgeons Pectoralis Major Transfer for Scapular Winging

Table 1 Results of Pectoralis Major Transfer for Scapular Winging Author(s) Number of Mean Mean (Year) Patients Patient Age Follow-Up Results

Steinmann, 9 34 years 70 months 4 excellent, 2 good, and 4 poor results. 7 patients returned to work. Two et al (2003) (21-47) (12-168) cases complicated by postoperative stiffness.

Noerdlinger, 15 33 years 64 months 2 excellent, 5 good, 4 fair, and 4 poor results by the Rowe criteria. Pain et al (2002) (17-44) (33-118) decreased in 11 patients, function improved in 10. 12 patients would undergo the procedure again. 13 patients returned to work. Two cases of postoperative stiffness, and 1 case of muscle hernia after fascia lata harvest.

Perlmutter, 16 33 years 51 months 8 excellent, 5 good, and 1 fair result. 14 patients returned to their previous et al (1999) (20-55) (25-108) employment, 9 patients returned to full recreational activities. Two graft failures associated with the use of fascia lata strip grafts early in the series.

Warner, et al 8 33 years 32 months 7 patients reported complete resolution of pain. Forward flexion (1998) (24-43) (24-40) improved from an average of 97° preoperatively to 150° postoperatively. One postoperative infection required graft removal.

Connor, et al 11 34 years 41 months 7 excellent, 3 satisfactory, and 1 unsatisfactory result by the Neer criteria, 2 (1997) (20-52) (12-84) of 4 heavy laborers returned to full duty, the other two returned to work with modifications. One graft failure 2 months postoperatively due to aggressive unsupervised physical therapy.

Post (1995) 8 NA 27 months All excellent results, all returned to work, 5 of 8 with modifications. (12-57)

NA = not available

Clavicle Scapular spine

Coracoid process

Deltopectoral groove

Anterior incision

Posterior incision AB

Figure 2 Anterior (left) and posterior (right) incisions.

American Academy of Orthopaedic Surgeons 441 Management of Neurologic Deficits/Muscle Weakness

Figure 3 Raphe between sternal and clavicular heads. The sur- Figure 4 The sternal head of the pectoralis major marked with Pen- geon’s finger bluntly dissects between the two heads of the pectora- rose drain, with the retractors pulling the clavicular head superiorly. lis muscle. nal tendon is clearly identified and ex- construct. If harvesting an autograft, the inferior pole of the scapula. A mal- posed at its insertion on the humerus. the ipsilateral knee should be pre- leable or similar retractor is placed be- A Penrose drain is passed around pared and draped free. The graft ten- tween the scapula and chest wall for the sternal head and used for traction don is doubled on itself with the free protection during drilling. Subse- while dissecting in a lateral direction ends sutured together, and is woven quently,a 7-mm drill or reamer is used toward the insertion site (Figure 4). through the pectoralis tendon. The to create a hole at the inferior angle of The tendon is sharply taken off the usually broad pectoralis tendon inser- the scapula. The point of entry is in humerus while protecting the long tion is then tubularized around the the thin bone just proximal to the head of the biceps, which is located graft tendon for a length of about 3 cm thickened medial and lateral scapular directly underneath. Medial dissec- using heavy nonabsorbable suture edges, resulting in bone bridges of ap- tion frequently is required to release (Figure 5). A tagging suture is then proximately 6 to 8 mm from the me- the sternal head from surrounding soft placed through the graft tendon to fa- dial, inferior, and lateral borders of the tissue, including fibrous bands to the cilitate passage of the construct during scapula (Figure 6). clavicular head. However, overly ag- the next step. Using blunt digital dissection, a gressive mobilization can lead to den- plane between the latissimus and the ervation and thus should be avoided. SCAPULA PREPARATION chest wall is developed to create a tun- The inferior pole of the scapula is di- nel connecting the anterior and poste- GRAFT PREPARATION rected toward the posterior incision rior approaches. The tunnel should be With adequate release of the pectoralis through gentle longitudinal traction of adequate size to facilitate graft pas- tendon off its humeral insertion site, of the arm and manual displacement sage and allow unrestricted tendon tendon length is usually sufficient to of the inferior pole of the scapula an- excursion. A long hemostat is directed reach the inferior border of the scap- teriorly and laterally. After superficial through the tunnel from posteriorly to ula, but the tendon is frequently not dissection, the latissimus muscle is retrieve the tagging suture and pass long enough for passage through the split in line with its fibers and re- the tendon construct. The graft ten- drill hole and secure fixation. A semi- tracted. The subscapularis, infraspina- don is pulled through the drill hole tendinosus autograft or allograft can tus, and serratus anterior muscles are from anterior to posterior until the be used to lengthen and reinforce the dissected subperiosteally to expose end of the pectoralis tendon is in con-

442 American Academy of Orthopaedic Surgeons Pectoralis Major Transfer for Scapular Winging

Figure 5 A, Graft tendon woven through the sternal head of the pectoralis major. B, Intraoperative photograph demonstrating thegraft woven through the pectoralis major.

section, and the skin is closed with a subcutaneous monofilament suture or staples. ■

■ Postoperative Regimen

Postoperatively,the upper extremity is immobilized in a sling for 4 weeks. Gentle passive range-of-motion exer- cises are started on the first postoper- ative day, preferably performed while supine to stabilize the scapula, to avoid adhesions of the tendon to the surrounding soft tissues. Formal Figure 6 Drill hole through the inferior scapular margin. physical therapy is initiated 7 to 10 days postoperatively with scapular isometric exercises with the arm at the tact with the scapula, which should be Wound Closure side, as along with closed chain pro- protracted and pushed as far lateral as Meticulous hemostasis is essential to traction and retraction exercises, pen- possible during this step. The graft reduce the risk of hematoma forma- dulum exercises, and passive and ac- tendon is then sewn to itself, the pec- tion; a drain can be used as necessary. tive assisted forward elevation to 90°, toralis major tendon, and the scapular The incisions are irrigated and closed abduction to 90°, and external rota- margin with heavy nonabsorbable su- in multiple layers to reduce the poten- tion to 50°. After 6 to 8 weeks, active ture (Figure 7). tial dead space created during the dis- range of motion without limitations is

American Academy of Orthopaedic Surgeons 443 Management of Neurologic Deficits/Muscle Weakness

Figure 7 A, The graft tendon sutured to itself and the pectoralis major tendon. B, Intraoperative photograph demonstrating the graft tendon passed through the scapular drill hole and sutured to itself. initiated in all planes. At 8 weeks, gen- ■ Avoiding Pitfalls velopment. Meticulous hemostasis, a tle periscapular strengthening is initi- and Complications drain, and activity restriction during ated, which at 12 weeks is expanded to the first postoperative week minimize include all muscles about the shoul- the occurrence of this complication. Correct identification of the raphe der. Patients are asked to refrain from To decrease the risk of graft separating the clavicular and sternal lifting more than 25 lb, and to avoid stretching, it is advisable to use a ham- heads of the pectoralis major muscle is contact sports or significant overhead string rather than fascia lata graft, and essential to avoid injuring the muscle, activities until 6 to 8 months postop- to double the graft onto itself for which could result in denervation and eratively. added strength. However, the avascu- limited excursion. lar graft is still at risk for elongation As with other muscle or tendon Correct graft tunnel placement transfers, patients will require retrain- and should therefore be used only to is important to avoid compression of augment, not to extend the vascular- ing of the transferred muscle tendon the brachial plexus between the graft ized pectoralis tendon. If used cor- unit. During retraining, the patient is and the chest wall. To avoid this com- rectly, the pectoralis major tendon asked to adduct the flexed arm against plication, the surgeon has to carefully should be in direct contact with the resistance, which facilitates activation elevate the latissimus and brachial inferior angle of the scapula to allow of the muscle transfer. Maintaining plexus off the chest wall before pass- direct healing of tendon to bone while adduction and flexing the shoulder ing the tendon. the graft acts solely to reinforce the anterior to the scapular plane ad- Fracture of the inferior pole of tenodesis. Toobtain maximum length, vances this activity. Good results have the scapula can occur if the hole is the pectoralis tendon should be taken been reported with additional biofeed- drilled too close to the scapular edge directly off its insertion on the hu- training as part of the postopera- or if overly aggressive physical ther- merus, and fascial bands that are fre- tive protocol, usually beginning 2 apy begins before graft incorporation. quently encountered medially should months postoperatively. A potential space is created dur- be carefully released during ing the dissection between the chest mobilization. ■ wall and latissimus muscle, placing the patient at risk for hematoma de- ■

444 American Academy of Orthopaedic Surgeons Pectoralis Major Transfer for Scapular Winging

■ References

Connor PM, Yamaguchi K, Manifold SG, Pollock RG, Flatow EL, Bigliani LU: Split pectoralis major transfer for serratus anterior palsy. Clin Orthop Relat Res 1997;341:134-142. Fox JA, Cole BJ: Pectoralis major transfer for scapular winging. Operative Techniques in Orthopaedics 2003;13:301-307. Litts CS, Hennigan SP, Williams GR: Medial and injury resulting in recurrent scapular winging after pectoralis major transfer: A case report. J Shoulder Elbow Surg 2000;9:347-349. Noerdlinger MA, Cole BJ, Stewart M, Post M: Results of pectoralis major transfer with fascia lata autograft augmentation for scapula winging. J Shoulder Elbow Surg 2002;11:345-350. Perlmutter GS, Leffert RD: Results of transfer of the pectoralis major tendon to treat paralysis of the serratus anterior muscle. J Bone Joint Surg Am 1999;81:377-384. Post M: Pectoralis major transfer for winging of the scapula. J Shoulder Elbow Surg 1995;4:1-9. Povacz P,Resch H: Dynamic stabilization of winging scapula by direct split pectoralis major transfer: A technical note. J Shoulder Elbow Surg 2000;9:76-78. Steinmann SP,Wood MB: Pectoralis major transfer for serratus anterior paralysis. J Shoulder Elbow Surg 2003;12:555-560. Warner JJ, Navarro RA: Serratus anterior dysfunction: Recognition and treatment. Clin Orthop Relat Res 1998;349:139-148. Wiater JM, Flatow EL: Long thoracic nerve injury. Clin Orthop Relat Res 1999;368:17-27.

■ Coding CPT Codes Corresponding ICD-9 Codes

23395 Muscle transfer, any type, shoulder or upper arm; single 736.89

CPT copyright © 2006 by the American Medical Association. All Rights Reserved.

American Academy of Orthopaedic Surgeons 445