ORIGINAL ARTICLE CiSE Clinics in Shoulder and Elbow Clinics in Shoulder and Elbow Vol. 18, No. 4, December, 2015 http://dx.doi.org/10.5397/cise.2015.18.4.229 Dynamic Stabilization of the Scapula for Serratus Anterior Dysfunction: A Retrospective Study of Functional Outcome and Results Soo Tai Chung* , Jon J. P. Warner1,* Department of Orthopaedic Surgery, Catholic Kwandong University International St. Mary’s Hospital, Incheon, Korea, 1Harvard Shoulder Service, Massachusetts General Hospital, Boston, MA, USA Background: Twenty-six patients (12 male and 14 female) with symptomatic scapular winging caused by serratus anterior dysfunction were managed by split pectoralis major tendon transfer (sternal head) with autogenous hamstring tendon augmentation from 1998 to 2006. Methods: Twenty-five patients showed positive results upon long thoracic nerve palsy on electromyography. The mean duration of symptoms until surgery was 48 months (range, 12–120 months). Four patients had non-traumatic etiologies and 22 patients had trau- matic etiologies. On follow-up assessment for functional improvement, a Constant-Murley score was used. Twenty-one patients were completely evaluated, while five patients who had less than 12 months of follow-up were excluded. Results: Pain relief was achieved in 19 of the 21 patients, with 20 patients showing functional improvement. The pain scores improved from 6.0 preoperatively to 1.8 postoperatively. The mean active forward elevation improved from 108o (range, 20o–165o) preoperatively to 151o (range, 125o–170o) postoperatively. The mean Constant-Murley score improved from 57.7 (range, 21–86) preoperatively to 86.9 (range, 42–98) postoperatively. A recurrence developed in one patient. Of the 21 patients, ten had excellent results, six had good results, four had fair results, and one had poor results. Conclusions: Most patients with severe symptomatic scapular winging showed functional improvement and pain relief with resolution of scapular winging. (Clin Shoulder Elbow 2015;18(4):229-236) Key Words: Split pectoralis major tendon transfer; Serratus anterior dysfunction; Scapular winging; Long thoracic nerve palsy Introduction infection, brachial neuritis, and iatrogenic injuries can lead to its dysfunction.2-7) When the balance of periscapular muscles is broken, ab- The serratus anterior muscle originates from the anterolateral normal scapulothoracic movement can develop. The most surface of the first 8 or 9 ribs, and inserts at the anterior surface symptomatic abnormal scapulothoracic movement is scapular of the medial border of the scapula. This muscle functions in the winging.1) The causes for scapular winging can be divided into protraction and lateral rotation of the scapula, and stabilizes the three groups; serratus anterior dysfunction, trapezius palsy and scapula while elevating the arm. The long thoracic nerve that facioscapulohumeral muscular dystrophy. Scapular winging innervates the serratus anterior muscle is long in shape and lo- caused by serratus anterior dysfunction is the most common cated subcutaneously over the ribs of the thorax ; therefore, it is disorder. Since the serratus anterior muscle has only one inner- very vulnerable to both direct and indirect injury.8) vation via the long thoracic nerve, incidents such as trauma, viral Although most patients with serratus anterior palsy can be Received September 30, 2015. Revised November 11, 2015. Accepted November 30, 2015. *These authors contributed equally to this paper as co-first authors. Correspondence to: Soo Tai Chung Department of Orthopaedic Surgery, Catholic Kwandong University International St. Mary’s Hospital, 25 Simgok-ro 100beon-gil, Seo-gu, Incheon 22711, Korea Tel: +82-32-290-2925, Fax: +82-32-290-3879, E-mail: [email protected] Financial support: None. Conflict of interests: None. Copyright © 2015 Korean Shoulder and Elbow Society. All Rights Reserved. pISSN 2383-8337 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. eISSN 2288-8721 230 Table 1. Patients Data (Causes & Results) Vol. 18, No. 4, December, 2015 18,No.4,December, Vol. Clinics inShoulderandElbow Case Sex/Age Injured Causes of Apprehension test/ Electromyographic Scapula Postop Postop Pain Active flexion Constant- Final Prior surgery www.cisejournal.org No. (yr) side injury instability symptom data stabilization test complication winging score (preop/postop) Murley score result 1 F/30 R (D) Ski injury No No LTN palsy + No No 5/0 110/170 64/98 E 2 M/45 L Idiopathic C6-7 laminectomy No LTN palsy + No No 4/0 90/150 61/93 E 3 M/31 L (D) Idiopathic Long thoracic nerve Yes LTN & DSN palsy + No Mild 8/2 165/165 76/86 G decompression 4 M/21 L Traction No No LTN palsy + - - 7/- 80/- 58/- - 5 M/33 R (D) Idiopathic No No LTN palsy - No No 7/2 90/160 64/88 G 6 F/38 L MVA No No LTN palsy - (no correction) No No 2/0 140/150 77/98 E 7 N/51 L Work-related No No LTN palsy + Pectoralis No 10/5 100/160 54/91 E muscle spasm 8 F/25 R (D) MVA No No LTN palsy + No No 10/2 80/155 40/93 E 9 F/33 R (D) MVA Bankart/Putti-Platt No/secondary LTN palsy + Recurrence Severe 8/8 90/80 44/42 P 10 F/46 R (D) Traction Anterior capsular Trace/secondary(?) Normal + No No 5/0 90/150 48/85 G shift 11 F/34 L Work-related No No LTN palsy + No No 5/2 90/140 52/78 F 12 F/35 R (D) MVA No No LTN palsy + No No 5/2 90/150 45/88 G 13 M/33 L Work-related Cervical discectomy No/secondary LTN palsy + Scapulothoracic No 10/5 160/160 55/75 F bursitis 14 F/16 R (D) Soccer injury No No LTN palsy + No No 5/0 130/160 72/98 E 15 F/30 R (D) MVA No Yes LTN palsy + No No 5/2 80/160 58/88 G 16 M/38 R (D) Work related No No/secondary LTN palsy + Idiopathic pain No 5/2 150/160 77/79 F syndrome 17 F/18 R (D) Lacrosse injury No No/secondary LTN palsy + No No 2/0 160/170 86/98 E 18 F/31 R (D) Work-related No No LTN palsy + No Mild 5/2 150/150 71/86 G 19 M/50 L (D) MVA No No LTN palsy + - - 5/- 110/- 56/- - 20 M/33 R (D) Idiopathic No No/secondary LTN palsy + No No 5/0 140/150 64/96 E 21 M/38 L (D) Work-related Acromioplasty No LTN palsy - (no correction) - - 8/- 80/- 42/- - 22 F/21 L Work-related No No LTN palsy + No No 5/0 90/170 54/98 E 23 F/29 L MVA Posterior No/secondary LTN palsy + No Mild 7/2 20/130 21/76 F capsulorraphy 24 M/48 R (D) Traction No No LTN palsy - (no correction) No No 8/2 60/125 28/91 E 25 F/38 R (D) Roller skating No No LTN palsy + - - 7/- 80/- -/- - injury 26 F/39 R (D) Work-related Cervical discectomy No LTN palsy + - - 5/- 150/- -/- - F: female, M: male, R: right, L: left, D: dominant, MVA: motor vehicle accident, preop: preoperative, postop: postoperative, LTN: long thoracic nerve, DSN: dorsal scapula nerve, E: excellent, G: good, P: poor, F: fair. Dynamic Stabilization of the Scapula for Serratus Anterior Dysfunction Soo Tai Chung and Jon J. P. Warner treated conservatively, prolonged scapular winging after 12 to 24 winging and weakness or loss of forward flexion of the arm. months of non-operative management is an indication of sur- In 25 of the 26 patients, long thoracic nerve injuries were gery.3,9) Different techniques have been introduced for the surgi- documented in the electromyographic data. All patients were cal stabilization of winged scapula.10-16) Today, the split pectoralis initially treated conservatively for at least 12 months: Most cases major tendon transfer is widely used for surgical management had the neuroplaxia-like paresis of long thoracic nerve, therefore of scapular winging.13,15,17-21) However, owing to their being few we recommended rest and inhibition of lifting activity above the examples and short follow-up periods, there is little information level of the scapula, which usually leads to complete recovery. available regarding this technique for large groups and complete The Costant-Murley score was used for postoperative functional functional outcomes. This study was conducted to evaluate the evaluation.22) The final results of the 21 patients were graded as functional outcome and clinical results in a relatively large group excellent, good, fair and poor. Patients were scored as excellent of patients with scapular winging caused by long thoracic nerve when they were satisfied with their results, exhibited painless, injuries. full use of the arm for daily living activity, and had a full range of motion in the shoulder without scapular winging (Fig. 1). Patients Methods received a score of good when they were satisfied with their results but had one or two of the following symptoms, including Patient Selection mild pain when using the arm for daily living activity, mild limita- Between 1998 and 2006, 26 patients with serratus anterior tion of motion in the shoulder and mild scapular winging. Pa- dysfunction caused by long thoracic nerve palsy were treated tients were scored as fair when they were not fully satisfied with with a split pectoralis major tendon transfer (sternal part) with their results, reporting mild pain when using the arm for daily liv- autogenous hamstring tendon augmentation.