technique and outcomes of arthroscopic scapulothoracic

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Technique and Outcomes of Arthroscopic ScapulothoracicBursectomy and Partial Scapulectomy

Peter J. Millett, M.D., M.Sc., LCDR Trevor R. Gaskill, M.D.,Marilee P. Horan, M.P.H., and Olivier A. van der Meijden, M.D.

Purpose: The purpose of this study was to assess the efficacy of arthroscopic scapulothoracicbursectomy in patients with snapping scapula syndrome with a minimum of 2 years’ follow-up.Methods: In this institutional review board–approved retrospective study, 23 shoulders in 21consecutive patients were identified that had undergone arthroscopic treatment of snapping scapulasyndrome. Each patient described mechanical symptoms with failure of nonsurgical modalities andreported symptomatic relief from a local anesthetic injection before surgical intervention. Preoper-ative and postoperative pain and functioning levels were assessed with the American Shoulder andElbow Surgeons (ASES), QuickDASH (shortened version of the Disabilities of the Arm, Shoulderand Hand questionnaire), and Single Assessment Numeric Evaluation (SANE) shoulder scores, andpatient satisfaction was recorded on a 10-point visual analog scale. Univariate and paired t tests wereused for data analysis. Significance was established at P � .05. Results: The mean age at the timeof surgery was 33 years (SD, 14 years). A scapulothoracic bursectomy alone was performed in 2shoulders, and the remaining 21 shoulders underwent both bursectomy and scapuloplasty of thesuperomedial or inferomedial scapular border. At a mean follow-up of 2.5 years (SD, 0.57 years), asignificant improvement in the median ASES score was noted, from 53 points (range, 17 to 83 points)preoperatively to 73 points (range, 32 to 100 points) postoperatively (P � .001). The mean SANEand QuickDASH scores at follow-up were 73 (SD, 27) and 35 (SD, 30), respectively. Overall, medianpatient satisfaction with surgical outcome was 6 of 10 (range, 1 to 10). Of the shoulders, 3 (13%)underwent revision for persistent scapulothoracic pain. Conclusions: Snapping scapula syndromecan be a debilitating disorder. Although significant pain and functional improvement can be expectedafter arthroscopic bursectomy and scapuloplasty, the average postoperative ASES and SANE scoresremain lower than expected. Level of Evidence: Level IV, retrospective case series.

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The scapulothoracic articulation is a criticalcomponent of normal shoulder function. The

onvex chest wall and concave anterior scapula

From the Steadman Philippon Research Institute (P.J.M.,M.P.H., O.A.v.d.M.), Vail, Colorado; and Naval Medical CenterPortsmouth (T.R.G.), Portsmouth, Virginia, U.S.A.

The authors report that they have no conflicts of interest in theauthorship and publication of this article.

The views expressed in this article are those of the authors anddo not necessarily reflect the official policy or position of theDepartment of the Navy, Department of Defense or the UnitedStates Government.

Received October 9, 2011; accepted May 31, 2012.Address correspondence to Peter J. Millett, M.D., M.Sc., Stead-

man Philippon Research Institute, 181 W Meadow Dr, Ste 400,Vail, CO 81657, U.S.A. E-mail: [email protected]

© 2012 by the Arthroscopy Association of North America
0749-8063/11652/$36.00http://dx.doi.org/10.1016/j.arthro.2012.05.889
1776 Arthroscopy: The Journal of Arthroscopic and Related Surg

ypically form a congruent articulation that is ableo glide smoothly on the interposed muscular andursal layers. Though uncommon, abnormalities within

his articulation can result in pain or mechanical symp-oms.1,2 These disorders range from mildly symptomatic,ntermittent bursitis to recalcitrant crepitus that may re-ult in considerable pain and disability in some circum-tances.3

Disorders of the scapulothoracic articulation can becharacterized based on etiology.4,5 When no mechan-ical symptoms are present, the pain is likely due to anoveruse syndrome resulting in symptomatic bursitis.This is frequently seen in young active patients andoverhead athletes.6 By contrast, the presence of me-chanical symptoms may indicate the presence of ab-normal bony or soft-tissue morphology within the
scapulothoracic articulation. Repeated impingement
ery, Vol 28, No 12 (December), 2012: pp 1776-1783

mailto:[email protected]

http://dx.doi.org/10.1016/j.arthro.2012.05.889

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1777ARTHROSCOPIC TREATMENT FOR SNAPPING SCAPULA

of these structural irregularities often results in con-comitant inflammation, bursitis, and scapular snap-ping.

Literature supports initial nonoperative manage-ment regardless of the etiology of the scapulothoracicpain.6 It is recognized, however, that bursitis occur-ring in the absence of an anatomic lesion respondsmore favorably to nonoperative management thanwhen an anatomic lesion can be identified. Whensymptoms do not respond to nonsurgical measures orin the presence of structural abnormalities, surgicalintervention is often necessary. Open techniques havehistorically resulted in substantial symptomatic relief.2

However, release of muscular insertions from thescapula can result in considerable morbidity and mayslow rehabilitation.1,7

Recently, arthroscopic techniques have been devel-oped to minimize surgical morbidity, improve cosme-sis, and accelerate rehabilitation. An understanding ofthe arthroscopic anatomy is critical to avoid the nu-merous neurovascular structures in this area, yet it isunfamiliar to many surgeons. There are also few clin-ical reports available to gauge the efficacy of an ar-throscopic technique. The purpose of this study was topresent the surgical outcomes of a large consecutiveseries of patients with scapulothoracic bursitis anddescribe an arthroscopic approach to scapulothoracicbursectomy and partial scapulectomy. It was our hy-pothesis that arthroscopic scapulothoracic bursectomyand partial scapulectomy would result in improvedsubjective shoulder outcome scores at a minimum of 2years’ follow-up.

METHODS

After obtaining institutional review board approval,we performed a retrospective review of prospectivelycollected data identifying all patients aged 18 years orolder treated arthroscopically for snapping scapulasyndrome in whom the index procedure had beenperformed a minimum of 2 years earlier. By use ofthese criteria, 23 shoulders in 21 consecutive patientswere identified over a 4-year period.

Each patient described mechanical symptoms withfailure of nonsurgical modalities and reported symp-tomatic relief from a local anesthetic injection placedalong the involved scapular border before surgicalintervention. Three-dimensional imaging was obtainedin each patient before surgical intervention to confirmbursal inflammation, characterize bony anatomy, andrule out the presence of scapulothoracic masses. Despite
a detailed analysis, none of the subjects had demonstra-
ble bony anatomic abnormalities with 3-dimensional im-aging. Pain levels preoperatively and at a minimum of 2years postoperatively were assessed (using a 10-pointvisual analog scale [VAS], where 0 indicates nopain), in addition to American Shoulder and ElbowSurgeons (ASES),8 Single Assessment Numeric

valuation (SANE),9 and QuickDASH (shortenedersion of the Disabilities of the Arm, Shoulder andand questionnaire)10 shoulder-specific scores.

Failures were defined as occurring in those patientsrequiring revision surgery for clinically persistentscapulothoracic crepitus. Overall patient satisfac-tion with surgical outcome was also recorded. Aunivariate Wilcoxon rank sum test and �2 were usedor analysis of data. Significance was established at

� .05.

rthroscopic Anatomy

The scapula is stabilized on the chest wall by itsurrounding musculature and is connected to the axialkeleton through the acromioclavicular and sternocla-icular joints. The levator scapulae and rhomboidusculature attach to the medial border of the scap-

la.3 The dorsal scapular nerve and artery run justeep to this musculature, approximately 1 to 2 cmedial to the medial border of the scapula (Fig 1). The

rapezius muscle originates from the thoracic and cer-ical spinous processes and inserts along the scapula,

FIGURE 1. Posterior view of right scapula showing the relevantneuroanatomy bordering the scapula. It should be noted that theportal sites are approximately 3 cm medial to the medial scapular
border to avoid these structures.

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1778 P. J. MILLETT ET AL.

superficial to the rhomboid musculature. The trapeziusis innervated by the spinal accessory nerve, whichruns deep to the muscle with the superficial branch ofthe transverse cervical artery. The main branches ofthese structures are at risk with portal placement cra-nial to the scapular spine.

The serratus anterior and subscapularis muscles areinterposed between the chest wall and anterior scapulaand provide a soft-tissue articulation for the scapulo-thoracic joint.11 The serratus anterior originates fromhe ribs and inserts on the anterior surface of theedial scapula. It is innervated by the long thoracic

erve, which lies on its anterior border. The anteriorurface of the scapula is the origin of the subscapu-aris, which is innervated along its anterior border byhe upper and lower subscapular nerves. These struc-ures are generally at low risk for injury during anrthroscopic resection.

The suprascapular notch is located just lateral to theunction of the medial two-thirds and lateral one-thirdf the superior border of the scapula. The suprascap-lar nerve and artery run toward the notch from annterior and cranial origin. An accessory superior por-al can be made at the junction of the medial one-thirdnd lateral two-thirds of the distance between theuperomedial angle and lateral acromion to facilitateesection of the superomedial scapula.12 Although we

do not routinely use this portal, it avoids neurovascu-lar structures near the superomedial scapular angleand the suprascapular neurovascular bundle more lat-erally.13

Bursal tissue lies between muscular planes and fa-cilitates gliding of the scapulothoracic joint (Fig 2).The supraserratus and infraserratus bursae are reliablypresent in dissections and at endoscopy.14 The in-fraserratus bursa is located anterior to the serratusanterior, between it and the chest wall.3,15 Conversely,he supraserratus bursa is located between the sub-capularis and serratus anterior.3

Minor bursae are also described but are inconsis-tently present and typically found in response topathologic scapulothoracic motion.3,6,7 Typically, 4are described and are located at the inferior angle ofthe scapula, superomedial border of the scapula eitherdeep or superficial to the serratus anterior muscle, anddeep to the trapezius muscle located at the medial baseof the scapular spine. Preoperative evaluation is crit-ical to determine which of these bursae are symptom-atic; however, bursae located along the superomedialborder and inferior angle of the scapula are most
commonly symptomatic.7 b
Technique

The patient is positioned in the prone position withthe nonoperative arm tucked to the side. The posteriorthorax is prepared widely, and the operative extremityis placed into a sterile stockinet. The dorsum of theoperative hand is positioned into the small of the back,effectively placing the glenohumeral joint into exten-sion and near maximal internal rotation. This positionis commonly known as the “chicken-wing position”(Fig 3). Winging of the scapula aids portal placementby increasing the potential space between the scapulaand the chest wall.1,7 Additional separation may beccomplished by placing a medially directed force onhe lateral shoulder, causing additional bayonet appo-ition of the scapular body.

Bony landmarks and symptomatic points confirmedefore anesthesia were marked, and approximately00 mL of normal saline solution with bupivacainend epinephrine was infused to distend the infraserra-us bursa and improve surgical hemostasis. Portalsere established 3 cm medial to the medial scapular

FIGURE 2. Posterior view of right scapula showing the anatomicocation of bursae that commonly become inflamed and symptom-tic. Dotted lines indicate areas underlying the bony scapularorders.

order and kept inferior to the scapular spine to reduce

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the risk of injury to the main branches of traversingneurovascular structures. Medial placement also al-lows bursal entry more parallel to the chest wall,thereby decreasing the risk of thoracic penetration.11

An initial viewing portal was made 3 cm medial tothe inferomedial angle of the scapula, and a 30° ar-throscope was introduced (Fig 2). Fluid pressure wasroutinely maintained at or below 50 mm Hg. A secondmedial portal was placed by triangulation, located 3cm medial to the scapula just inferior to the medialconfluence of the scapular spine (Fig 2). A diagnosticarthroscopy was performed once adequate visualiza-tion was established. The intercostal muscles and ribswere visualized inferiorly, the subscapularis was vi-sualized laterally, and the rhomboid and levator mus-culature was identified medially. A spinal needle wasplaced along the superomedial scapular border foradditional orientation (Fig 4). Red muscle fibers of thesubscapularis were not resected because a shaver orradiofrequency ablator was used to clear bursal tissueand fibrous bands in order to skeletonize the supero-medial scapular border. The supraserratus bursa wasaccessed similarly by bluntly penetrating the serratusanterior.

The superomedial angle of the scapula was exposedby removing the underlying muscular attachmentswith a radiofrequency probe. If crepitus or snapping ofthe scapula was clinically evident after the superome-dial angle of the scapula was exposed, spinal needleswere placed to mark the extent of the planned resec-

FIGURE 3. Surgically prepared right scapula with the patient inthe prone position. The dorsum of the operative hand is positionedinto the small of the back, effectively placing the glenohumeraljoint into extension and near maximal internal rotation. This posi-tion is commonly known as the chicken-wing position.

tion.1 An arthroscopic scapuloplasty was then per-

ormed with a high-speed bur, removing a triangularection of bone of approximately 2 cm (superior tonferior) by 3 cm (medial to lateral). Resection ade-uacy is determined by removing the scapular borderonvexity as determined arthroscopically and typi-ally requires resection of 2 to 3 cm of bone (Fig 4).

dynamic examination of the scapula with the patientnder anesthesia should also be routinely performed tonsure adequate clearance to ensure that residual me-hanical crepitation does not persist. The suprascapu-ar nerve can be at risk if this resection is taken too faraterally. To ensure that the nerve is protected, ar-hroscopic instruments should proceed no further thanhe spinal needle placed to mark the extent of scapularesection.12 The resection is viewed from both portals

to ensure that it is smooth and that there is adequateclearance (Figs 5 and 6). Because the scapular bone isuite thin, a rasp is typically used to contour resecteddges. The arm is dynamically ranged to ensure thato mechanical crepitation remains.A superior accessory portal has also been described

o aid the resection of the superomedial scapula.12,13 Itis located at the junction of the medial one-third andlateral two-thirds of the distance between the supero-medial scapular angle and the lateral acromion. Thetrocar is advanced in a medial and caudal direction. Itis important to remain relatively close to the anteriorportion of the scapula to avoid intrathoracic penetra-tion. Although this portal can be helpful, it was notused in this series. Portals are closed routinely, and asling is applied postoperatively.

FIGURE 4. Intraoperative image of a right scapula in the proneposition. A second medial portal may be placed by triangulation,located 3 cm medial to the scapula, just inferior to the medialconfluence of the scapular spine. A spinal needle (arrow) can beplaced along the superomedial scapular border for additional
orientation.

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Rehabilitation

Arthroscopic bursectomy and scapuloplasty are typ-ically performed as outpatient procedures; a sling isapplied for postoperative comfort only, and its use isdiscontinued within the first 48 hours postoperatively.Because there is no true joint capsule, there is typi-cally a moderate amount of swelling that occurs thatcan extend into the ipsilateral breast. This typicallyresolves within a few hours postoperatively. Activeand passive motion begins immediately and includesscapular protraction and retraction. Patients are thenallowed to progress as tolerated under the guidance ofan experienced therapist. Patients typically begin iso-metric strengthening of the glenohumeral joint at 4

FIGURE 5. Arthroscopic images of a left scapula with the patient i(B) after resection of the superomedial border of the scapula (aste

FIGURE 6. (A) Anteroposterior shoulder radiograph and (B) 3-di
rthroscopic scapuloplasty and bursectomy. The absence of the superome
weeks, and periscapular strengthening begins aroundthe eighth postoperative week. Return to sports andoverhead activities typically occurs around the secondto third postoperative month based on progress withtherapy.

RESULTS

Minimum 2-year follow-up was available for 21 of23 shoulders (91%). The mean age at the time ofscapula surgery in this series was 33 years (range, 19to 58 years). There were 12 men and 9 women. Themedian duration of symptoms before presentation was2.0 years (range, 2 months to 12 years). No scapulo-

rone position from the inferomedial scapular portal (A) before and

nal computed tomography reconstruction of a right shoulder after
mensio dial scapular angle (arrows) should be noted.

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thoracic bony or soft-tissue masses were identified on3-dimensional imaging. A scapulothoracic bursec-tomy alone was performed in 2 shoulders because ofthe lack of mechanical symptoms on physical exami-nation.

At a mean follow-up of 2.5 years (SD, 0.6 years), asignificant improvement in the median ASES scorewas noted, improving from 53 points (range, 17 to 83points) preoperatively to 73 points (range, 32 to 100points) postoperatively (P � .001). The median VAScore for pain at its worst decreased from 9 (range, 5o 10) to 5 (range, 0 to 10) (P � .001). The meanANE and QuickDASH scores at follow-up were 74SD, 27) (range, 15 to 100) and 35 (SD, 30) (range, 0o 89), respectively. Patient satisfaction with surgicalutcome was 6 of 10 (range, 1 to 10). Overall patientatisfaction was higher in women (9 of 10; range, 2 to0) than in men (2 of 10; range, 1 to 9) (P � .043).A correlation between age and both ASES scores

(� � �0.616, P � .006) and overall patient satisfac-tion (� � �0.675, P � .004) was identified. Thisorrelation indicates that younger patients hadmaller improvements in the ASES score and wereess satisfied with their outcome overall. Patientsho underwent arthroscopic bursectomy alone were

ignificantly less satisfied with the procedure com-ared with those who received both bursectomy andcapuloplasty (P � .045).

Two patients required ipsilateral shoulder surgeryunrelated to the scapula after the index procedure(glenoid fracture, subacromial decompression with bi-ceps treatment) postoperatively. Of 23 shoulders, 3(13%) were revised for persistent pain and scapulo-thoracic crepitus and were considered failures. Twoshoulders underwent a revision scapuloplasty at 4weeks and 16 months, whereas the third shoulderunderwent a scapulothoracic bursectomy 7 monthsafter the index procedure without additional symptom-atic improvement. No surgical complications werenoted in this series of patients.

DISCUSSION

This series shows that a significant improvement inboth the ASES score and VAS score for pain can beachieved after arthroscopic management of scapulo-thoracic crepitus. It appears that this technique pro-vides a reliable and safe method of decompression forsurgeons with a thorough appreciation of arthroscopicscapulothoracic neuroanatomy. It is also apparent that
although symptomatic improvement with surgery was
considerable, incomplete resolution of symptoms oc-curred.

Although the cause of persistent pain despite scapu-loplasty and complete bursectomy remains unclear,several possible explanations exist. First, superome-dial adventitial bursae may exist in an infraserratus orsupraserratus location.14 Unless directly accessed or ascapuloplasty is performed, only the infraserratusbursa is typically removed. Therefore incomplete painresolution may occur if this bursa is symptomatic andnot addressed. For this reason, it is now our routinepractice to expose this border in all patients regardlessof the presence of mechanical symptoms. Alterna-tively, recurrent fibrous adhesions have been noted inseveral revision cases. It is possible that these adhe-sions become symptomatic in some patients and canbe addressed with revision bursectomy and physicaltherapy.

Snapping scapula syndrome can be managed suc-cessfully with a focused scapulothoracic and shouldergirdle rehabilitation program in many patients.15

When appropriately applied, success rates of theseprograms have been reported to resolve symptoms in50% to 80% of patients.16,17 Therapeutic exercise ap-pears to be most successful in patients in whom noanatomic abnormality can be identified on imagingstudies. Under these circumstances, bursal irritation istypically the result of shoulder girdle overuse syn-dromes and responds well to activity modification,nonsteroidal agents, or therapeutic injection.

Scapulothoracic bursitis and snapping scapula syn-drome have traditionally been managed using opensurgical techniques.2 In general, authors have reportedsuccessful outcomes using open procedures and ap-pear to respond more favorably when a structuralabnormality is present.14,18-24 Other authors have sim-larly reported high rates of subjective pain relief andeturn to desired activity levels in this patient popula-ion.2,25 The results of arthroscopic management ofnapping scapula syndrome appear to be similarlyuccessful in small cohorts of patients.15,26

Comparative studies of open and arthroscopic sur-gical techniques are not currently available to ourknowledge. For this reason, the optimal managementtechnique is not firmly established.27,28 Arthroscopicapproaches, however, may provide several advantagesover traditional open techniques. To this end, musclesare typically detached and ultimately repaired to themedial border of the scapula during open procedures.Muscular detachment may increase surgical morbidityand dysfunction if the repair fails or denervation oc-
curs. Avoiding muscular detachment may also facili-

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tate accelerated rehabilitation protocols. By contrast, itis clear that arthroscopic intervention is a technicallydemanding procedure primarily because surgeons areunfamiliar with the arthroscopic anatomy of this re-gion.

Although outcomes detailing the open or arthroscopicsurgical management of snapping scapula syndromeappear encouraging, more quantitative reports indicatethat some magnitude of disability persists postopera-tively. Lien et al.29 reported a significant improvementn ASES and pain scores in a series of 12 patients.espite this improvement, the mean postoperativeSES and pain scores were 88 and 2.3 points, respec-

ively. Other authors have reported that in the absencef a discernible bony abnormality, satisfactory out-omes are achieved in only 70% of patients.30 Our

series supports these findings and suggests that a sig-nificant improvement in patient satisfaction scores andpain levels can be reliably expected. Yet, to date,surgical intervention is not likely to relieve all shoul-der symptoms or restore normal shoulder function inall patients. This is an important patient educationconsideration when discussing surgical interventionwith prospective patients.

We acknowledge several limitations to this study.The data were retrospectively reviewed; however, re-call and observation biases were minimized by theprospective data collection of our clinical database. Inaddition, the series size precludes detailed analysis ofspecific prognostic indicators for patient outcomes,and a comparative group was not included in thisseries. Considering the rarity of this disorder and thefrequent success of nonsurgical intervention, a largeseries capable of this type of analysis will be difficultto accrue. Two patients subsequently required ipsilat-eral shoulder surgery unrelated to the index procedure(glenoid fracture, subacromial decompression with bi-ceps treatment). It is unclear what effect these addi-tional procedures had on reported outcomes.

CONCLUSIONS

Snapping scapula syndrome can be a debilitatingdisorder. Although significant pain and functional im-provement can be expected after arthroscopic bursec-tomy and scapuloplasty, the average postoperativeASES and SANE scores remain lower than expected.

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technique and outcomes of arthroscopic scapulothoracic

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