Chapter 46 Pectoralis Major Transfer for Scapular Winging Andreas H. Gomoll, MD Brian J. Cole, MD, MBA ■ Indications before traveling along the lateral as- ■ Contraindications pect of the thorax. The superficial lo- Scapular dysfunction is a relatively cation makes it susceptible to blunt Associated paralysis of the trapezius 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, brachial plexus because it compromises the results of includes deconditioning and primary neuritis (Parsonage-Turner syn- pectoralis major transfer. If present, shoulder 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 scapula and rhomboid symptoms. Occasionally, scapular nerve 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- Long thoracic nerve palsy usu- ability to transfer the tendon able functional limitations and pain, ally resolves within 8 to 12 months appropriately. especially with overhead activities or but can last up to 2 years in infectious ■ when the arm 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 upper limb. 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 serratus anterior muscle 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 fascia 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 anesthesia The pectoralis major tendon inserts Traditionally, failure rates for pectora- reduces postoperative pain and de- on the humerus 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 Acromion 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.