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Surgical Management of Scapular Osteochondroma Anatomical Considerations: Tips And Tricks
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Surgical Management of Scapular Osteochondroma Anatomical Considerations: Tips And Tricks
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2024-05-31T00:00:00.0000000
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Language: EN.
Segment:0 .
Hello, my friends, how are you? This is me, Dr. Sergio Rowinski, here from Sao Paulo, Brazil, from SHOULDERPLANET. And today I'm showing you a very interesting video, very nice about how to do this surgical resection of scapular OSTECHONDROMAS. These are quite unusual tumors, but they happen, and it's important to know how to manage them, when they have a surgical indication.
So I hope you like the video. Please give your thumbs up. Leave your comment. Subscribe, and let us see the video. So this case is about a young girl, of 40-year-old girl, who had multiple OSTEOCHONDROMATOSIS in her body. That was a condition that she had since her childhood. And she had an enormous OSTEOCHONDROMA below her right scapula, anteriorly of her right scapula, which was giving her a lot of symptoms.
And in that sense, that tumor had to be, hence, removed. So when we take a look at the X-rays of that patient, we can easily see, here I'm going to show you now, here, we see in the proximal middle, in the proximal third of the humerus, laterally, as I am showing here, with my arrow, ee had one osteochondroma, and here we see another one, in the medial part of the shaft of the humerus. On the right scapula, as I am showing here,
there was a very, very big sosteochondroma, and here, when we see a well done lat view of the shoulder, it's very easy to see a very, very big osteochondroma in the very inferior part of the right scapula. In this case, this is very interesting for us to do an MRI, or even a CT. Here this is a left view of the CT, in which we can easily see the tumor.
And this is, here, another view, a transverse view, I'm coming now, in which we can easily see that was, indeed, a big osteochodroma. It's important for us to understand that these tumors, they are much bigger than they seem to be in the CT, because the cartilage part of the tumor, obviously, as we all know, this doesn't appear in the CT The 3D CT is a very good exam for us to see the osseous part of this tumor.
Here we can see, as I am showing with my my, my arrow, a very big tumor, a very big osteochondroma, and here, from a superior view, it's quite easy for us to see the tumor. And here this is another view, anterior view, in which we can see the Australian Roma in the very inferior part of the scapula. So this girl, she would have to be operated.
And now we are seeing, here, as I am pointing with my arrow, that she had a protuberance, on the right scapula,that was indeed pulling the right scapula back. So when she elevated here, as I am showing with my arrow, we can see the tumor that was indeed quite big, and that was really bothering that girl, for about one year. She's now elevating again.
And now after that, I'm going to palpate the tumor, which which was, at that moment, quite simple, because of its size. So when we think about the surgery, it's interesting to discuss the muscle sparing technique, which is a technique I'm going to comment upon now, in which we basically don't detach any insertion. But the inferior insertion of the rombhoids, the patient must be operated in lateral position, and in my opinion, in prone position is quite better.
And it's very important to highlight that the whole arm must be involved in the surgery. So that was the surgical incision and that was the tumor. So let's take a look now in the muscle sparing technique. So when we think about the technique, the muscle sparing technique, we have to take a very good notion of anatomy. So when we take a look at the nerves that are involved in the region, we are seeing, here, the spinal accessory nerve, and very close to that nerve,
We have the long thoracic nerve and the thoracodorsal nerve, and we must avoid these muscles for obvious reasons. So when we think about the approach, is interesting to see that this approach is done in a region which is called the triangle of auscultation. And we must really understand the landmarks, the anatomical landmarks to do this approach.
So when we look at the back of the patient, we see a triangle. So let's understand the triangle. We have here the trapezius, the superior trapezius, the medial trapezius we see here, the lat dorsi and, here the medial border of the scapula. So when we see here, we have a triangle, and this is the triangle in which we will work, with the muscle sparing technique.
So again, the surgeon must retract superiorly the trapezius, and inferiorly the lat dorsi. And, in that sense, here we'll see, so, the triangular area in which he must work. And this is exactly the approach that we will see, this is not exactly this case, but this is another case of mine, in which we can see clearly, here, this is the right side of the body.
Here we see the inferior border of the scapula, and, here, the thorax and ribs. So what is interesting is that when we have this approach, and as long as we just do a delicate dissection, and a very delicate detachment of the very inferior part of the rhomboids, we have a very good view and, as long as we attach the inferior insertion of the rhomboids, the approach will be finished.
And in the end, this is a very, very muscle saving approach. So again, this is the big osteochondroma, that we are seeing, here, I'm pointing with my arrow, and it's quite easy for us to see a big cartilage layer, which is part of this tumor. Of course, this is another video, I'm sorry, a photo, in which we can see a very big cartilage and those parts that can only appear in the MRI.
And this is a video showing the. tumor. So, at that moment, we had to come delicately, with small, osteotomes and some rongeurs, and take it out. So that is, here, the final view, just after resection of the tumor. As we can see, we could not resect the tumor in block, but in small pieces, and that was the only way we could do it.
But anyway, we did a full resection of that tumor. And it's important to highlight that that girl had a very, very good final clinical outcome. So when we take a look in literature, we find quite interesting and useful information for us to manage this particular problem. So when we see this interesting article, published about in International Journal of Surgery Case reports, we can find very useful information.
So, from the epidemiological point of view, osteochondromas indeed they are benign tumors, with a cape, with a cape of cartilage. They always happen in between below a cartilage layer, and they do affect long bones in immature skeletons. So we are talking about kids and adolescents, and it's quite easy to diagnose them in the appendicular skeletons, it means, in legs, in arms, in distal femur and proximal tibia.
And when they happen on this location, making the diagnosis becomes quite easy. Anyway, when we have non typical or atypical localizations, like the scapula, the diagnosis can be quite difficult, even by clinical evaluation, plane X-rays. So, the message is, we must have a high index of suspicion when we are dealing with these problems, and even knowing that osteochodromas of the scapula, they are quite rare,
ee must hawe them into consideration when we have patients with these problems. When we think about the surgical technique, is interesting to say that, indeed, literature is quite poor, it's quite poor about surgical techniques to remove such benign tumors. And in this sense, it's very interesting for us to know and to consider the aspect of the muscle sparing techniques.
So in fact, the muscle sparing technique offers a very good and fast rehabilitation for patients operated on these cases, because it doesn't detach the muscles, but, rather than that, we just have to retract the superior trapezius and the medial trapezius, and split the rhomboids. And, in this sense, surgical removal is quite useful, in these cases, because it eliminates pain, discomfort and still it avoids the future of malignizartion of the tumors,
on timeline, in spite of the fact that such malignizations are quite improbable, from an epidemiological point of view. And when we take a look at on this other article, a quite interesting one, about surgical management of scapular osteochondromas, we find, somehow, the same information. So, indeed, the vast majority of the osteochondromas, something about 90%, they happen in the metaphysis of long bones, especially distal femur and proximal tibia,
and, in this sense, it's quite easy to diagnose them when they happen on those places. But, as I have said, it's difficult to diagnose in this scapula. And what would be the symptoms that those scapula osteochondromas would cause? Well, of course, pain, limited range of motion, subacromial impingement, and this is what we call non outlet impingement, scapula winging, and even nerve compressions, which, in my opinion, is quite rare.
But nevertheless, all of these symptoms, they can happen because of scapular or osteochondromas, and, in this sense, we must keep this in mind, as a differential diagnosis. It's important to say that the vast majority of the problems that occur around scapula, they are caused by scapular dyskinesia, and I would say, as a rule, muscular imbalances around the scapula, and in that sense, conservative management is the Super rule but, nevertheless, we must have all of these ideas of scapular osteochondromas, and its respective symptoms in our minds. When we think about the surgical technique,
again, this article comments upon the idea of the muscle sparing technique, and the steps of the surgery would be to identify the superior trapezius fascia and then reach retract the medium trapezius and the superior trapezius superiorly.. We would, then, split the rhomboid fibers, as we did in this case, and then we would see the osteochondroma. And once we see it, we have to expose it, and remove it, with a nastier tone and some roungeurs.
Anyway, the fact is, very good clinical outcomes can be expecting, with the muscle sparing, the muscle sparing technique, for patients under such situations. So thank you, my good friends for watching. I'm Dr. Sergio Rowinski, from shoulder planet, here from Sao Paulo, Brazil. Shoulder planet is my personal project in international education, in shoulder and elbow medicine and surgery.
You can always send me an email, whenever you wish, or leave a comment, here below the video. And don't forget to spread YouTube channel of SHOULDERPLANET YouTube channel and help me on this big journey on shoulder and elbow education. Ok? thank you, my friend. See you, so I hope you liked the video. Please don't forget my good friends. Subscribe, leave your comment.
Give us your thumbs up. And as Dr. Sergio always says, never stop flying. See you, all my good friends.