Evolving Technique: Resect the Superomedial Angle John E. Kuhn, MD, - - PowerPoint PPT Presentation

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Evolving Technique: Resect the Superomedial Angle John E. Kuhn, MD, - - PowerPoint PPT Presentation

Mar 25, 2023 326 likes •652 views

Evolving Technique: Resect the Superomedial Angle John E. Kuhn, MD, MS Kenneth D. Schermerhorn Professor of Orthopaedics Chief of Shoulder Surgery Vanderbilt University Medical Center V A N D E R B I L T S P O R T S M E D I C I N E Snapping

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V A N D E R B I L T S P O R T S M E D I C I N E

Evolving Technique: Resect the Superomedial Angle

John E. Kuhn, MD, MS Kenneth D. Schermerhorn Professor of Orthopaedics Chief of Shoulder Surgery Vanderbilt University Medical Center

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V A N D E R B I L T S P O R T S M E D I C I N E

Snapping Scapula

  • Snapping may not be

pathologic

  • Snapping may lead to

bursitis which is symptomatic

  • “sound about the room

without the slightest pain”

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V A N D E R B I L T S P O R T S M E D I C I N E

IMPORTANT POINTS

  • Crepitus May NOT be Symptomatic
  • Crepitus and Bursitis MAY BE Related
  • Treatment

– Nonoperative – Arthroscopic – Open Surgery

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V A N D E R B I L T S P O R T S M E D I C I N E

Snapping Scapula

  • Degrees (Mauclaire 1904)

– Froissement-physiologic – Frottemont-louder grating sometimes pathologic – Craquemont-always pathologic

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V A N D E R B I L T S P O R T S M E D I C I N E

Causes of Snapping Scapula

  • Soft Tissue

– Bursitis – Tuberculosis – Syphylitic

  • Muscle

– Atrophy – Fibrosis – Anatomic Variants

  • Bone

– Osteochondroma (Scapula and Rib) – Fracture (Scapula and Rib) – Hooked Superomedial Angle – Luschka’s Tubercle – Reactive Spurs-Muscle Avulsion

  • Congruence

– Scoliosis – Kyphosis – Postural

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V A N D E R B I L T S P O R T S M E D I C I N E

Luschka’s Tubercle

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V A N D E R B I L T S P O R T S M E D I C I N E

Bursal Anatomy

  • Natural Bursae
  • Adventitial Bursae
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V A N D E R B I L T S P O R T S M E D I C I N E

Scapulothoracic Bursitis

  • History of Overuse
  • Swelling/Pain along Medial

Border

  • May have Subtle Winging
  • May have Crepitus
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V A N D E R B I L T S P O R T S M E D I C I N E

Inferior Angle Bursitis in Throwers

  • Rare
  • Swelling/Pain in

Cocking

  • May Require

Surgical Excision

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V A N D E R B I L T S P O R T S M E D I C I N E

Clinical Assessment

  • History

– Pain

  • Location
  • Aggravating Features

– Popping

  • Physical Exam

– Scapula Exam – Demonstrate Snapping?

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V A N D E R B I L T S P O R T S M E D I C I N E

Clinical Assessment Inferior Angle Bursitis

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V A N D E R B I L T S P O R T S M E D I C I N E

Snapping Scapula

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V A N D E R B I L T S P O R T S M E D I C I N E

Nonoperative Treatment

  • Postural Correction

– Figure of 8 brace

  • Subscapularis/Serratus

Muscle Strengthening

  • Injections into Bursa

– Watch for Pneumothorax

  • Coaching
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V A N D E R B I L T S P O R T S M E D I C I N E

Surgical Treatment of Scapular Bursitis and Snapping Scapula

  • ARTHROSCOPIC
  • OPEN
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V A N D E R B I L T S P O R T S M E D I C I N E

Arthroscopic Treatment

  • Mark Landmarks
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V A N D E R B I L T S P O R T S M E D I C I N E

Portal Placement

Avoid Neurovascular Structures

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V A N D E R B I L T S P O R T S M E D I C I N E

Inject the Bursa

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V A N D E R B I L T S P O R T S M E D I C I N E

Insert Scope Blunt Tools

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V A N D E R B I L T S P O R T S M E D I C I N E

Views

NOT IN BURSA IN THE BURSA

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V A N D E R B I L T S P O R T S M E D I C I N E

Osteochondroma

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V A N D E R B I L T S P O R T S M E D I C I N E

Open Surgery

Resection of the Superomedial Angle

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V A N D E R B I L T S P O R T S M E D I C I N E

Subperiosteal Resection

  • Window through

Trapezius

  • Elevate

Supraspinatus

  • Shell out SM

Angle and Remove

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V A N D E R B I L T S P O R T S M E D I C I N E

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V A N D E R B I L T S P O R T S M E D I C I N E

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V A N D E R B I L T S P O R T S M E D I C I N E

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V A N D E R B I L T S P O R T S M E D I C I N E

Surgical Treatment

  • Resect Abnormal Bone
  • Resect Bursa
  • Superomedial Angle Resection
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V A N D E R B I L T S P O R T S M E D I C I N E

Results of Surgery

  • All Case Series
  • 85-90% success
  • Allow return to unrestricted activity
  • PEARLS:

– Shell Out the Bone in a Subperiosteal Plane – Meticulous Repair of Muscle Plane – Repair to Bone When Possible

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V A N D E R B I L T S P O R T S M E D I C I N E

Summary

  • Scapulothoracic Crepitus is NOT Uncommon
  • It may be ASYMPTOMATIC-Watch for

Secondary Gain!

  • Crepitus and Bursitis May Occur together or

May be Independent

  • Nonoperative Treatment is an Option
  • Surgery, If Required is usually successful
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V A N D E R B I L T S P O R T S M E D I C I N E

Thank You