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Partial scapulectomy for chondrosarcoma

    Overview

    Learn the Partial scapulectomy for chondrosarcoma surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Partial scapulectomy for chondrosarcoma surgical procedure.
    Osteochondromas represent approximately 1/3 of all benign bone tumours. They are an exostosis of bone that is covered by cartilage on its external surface. They typically present in the second or third decades of life and most frequently effect the appendicular skeleton, with the lower-limbs more commonly effected. They may be solitary or multiple hereditary osteochondromas. The risk of sarcomatous change is rare, seen in approximately 1% of solitary osteochondromas, with rates of 2-5% seen in hereditary multiple osteochrondromatosis (as in this case). Although classically osteochondromas are encountered in the metaphyseal region of appendicular long bones, axial tumours of the pelvis, spine, ribs, and scapula.
    Surgery for benign osteochondromas should be avoided and only performed if they cause pain, decreased range of motion, pressure on neurovascular structures, tendon irritation or significant bursal formation. Clearly any clinical, pathological or radiological evidence of malignant transformation is also an indication for wide ‘en-bloc‘ resection of a possible chondrosarcoma.
    In this case a young female patient suffered pain and limitation of movement as the osteochondroma continued to enlarge after skeletal maturity, a concerning feature of malignant transformation. An MRI pre-operatively had not excluded the possibility of malignant transformation and the biopsy was typically reassuring but subject to the sampling error renowned when biopsying possible chondrosarcomas. Unfortunately chondrosarcomas are not homogenous, and consequently high grade chondrosarcomas when carefully scrutinised after resection will have benign, low-grade and high-grade areas all within the same tumour, thus biopsy is considered unreliable. This has been reported by multiple research teams (Laitinen MK, Stevenson JD, Parry MC, Sumathi V, Grimer RJ, Jeys LM. The role of grade in local recurrence and the disease-specific survival in chondrosarcomas. Bone Joint J. 2018 May 1;100-B(5):662-666. doi: 10.1302/0301-620X.100B5.BJJ-2017-1243.R1. PMID: 29701096). The sarcoma MDT took the view that given the clinical and radiological features were concerning for sarcomatous transformation in a pre-existing osteochondroma, that en-bloc excision was indicated.
    Malawer classified shoulder girdle resections for patients undergoing limb sparing procedures for bone and soft tissue tumours: Type I, proximal humeral resection; type II, partial scapular resection; type III, total scapulectomy; type IV, total scapulectomy and extra-articular glenohumeral resection; type V, proximal humeral and glenoid resection; and type VI, proximal humeral and total scapular resection. Here we present a type II partial scapulectomy for peripheral chondrosarcoma without reconstruction.
    OrthOracle reader will find the following related operative techniques also of interest:
    Forequarter amputation for chondrosarcoma
    Computer navigated P1 hemipelvectomy for chondrosarcoma and GRAFTJACKET (Wright Medical) reconstruction
    Hindquarter amputation with pedicled fillet flap for clear cell chondrosarcoma of the proximal femur
    Proximal femoral endoprosthetic replacement (Stanmore METS, Stryker) for chondrosarcoma

    Indications

    INDICATIONS
    Indications for surgical removal include pain secondary to the tumour itself, or due to symptomatic compression of local anatomy such as nerve, blood vessels or tendons. Patients with hereditary multiple osteochodromatosis (HMO) (also known as hereditary multiple exostoses and diaphyseal aclasia) have growths of multiple osteochondromas, benign cartilage-capped bone tumours that grow outward from the metaphyses of long bones. HMO can be associated with a reduction in skeletal growth, bony deformity, restricted joint motion, shortened stature, premature osteoarthritis, and compression of peripheral nerves. Nearly all individuals are diagnosed by age 12 years, aided by a strong family history. Often as children have growth spurts, so too do their osteochondromas, which then become more prominent and symptomatic. These patients may also require surgery to correct deformities of the upper and lower-limb (e.g. ulna shortening osteotomies) and guided-growth for limb-length discrepancy.
    Both solitary and multiple osteochondromas grow with children until they reach skeletal maturity. Any increase in size after skeletal maturity is concerning for malignant transformation which is rare, possibly 1% in solitary osteochondromas and 2-5% in hereditary multiple osteochondromatosis. Malignant transformation is more common in pelvic and scapula (axial) sites, less common around the knee and exceptional in the extremities.
    There are no clear guidelines for management of these patients throughout their lives but commonly they are managed by local paediatric surgeons until lesions require more specialist care at tertiary orthopaedic oncology centres (in my experience). There are also no guidelines for surveillance but my personal preference is to do a baseline whole-body MRI at skeletal maturity so that we have imaging to compare with any future MRI scans querying malignant transformation in the future.
    SYMPTOMS & EXAMINATION
    They normally present as a painless mass though can cause symptoms secondary to formation of an overlying bursa due to friction, or to activity-related discomfort. Very occasionally, the lesion may cause neuropathic symptoms due to compression of a nearby nerve or may fracture producing sudden pain. They may well also be asymptomatic. In this case the gradual growth of the tumour had caused deformity of the underlying rib-cage, was painfully limiting scapulothoracic movement and causing difficulty with clothing.
    If present symptoms will include pain, decreased range of motion, pressure on neurovascular structures, tendon irritation or significant bursal formation. A sudden change in symptoms should prompt re-evaluation and may indicate malignant transformation to a chondrosarcoma.
    Such secondary peripheral chondrosarcomas arise in the cartilage cap of a longstanding osteochondroma. Those located in the pelvis and scapula seem to be the most susceptible to malignant change, perhaps because these sites permit undetected growth. Malignant transformation occurs in 1% of solitary osteochondromas and unto 5% of patients with hereditary multiple osteochondromatosis. This change is often seen in the fourth decade. HMO is an autosomal dominant disorder; in almost 96% of MO patients germline mutations in the tumour suppressor genes EXT1 or EXT2 are present, meaning that the remainder are de-novo variants.
    IMAGING
    Xray findings are very characteristic and allow quantification and documentation of size and location.
    The lesion appears as a bony protuberance with well-defined limits, thin outer cortex and an inner cancellous structure. The pathgnomic feature is that the host bone flares from the cortex into the osteochondroma. Some are pedunculated with a cauliflower-like summit, whilst others have a broad, sessile base. Pedunculated osteochondromas typically point away from the joint, towards the diaphysis.
    MRI demonstrates the classic cartilaginous cap which ranges from a few millimetres to a centimetre or more. The cap is typically thicker in children diminishing with age. MRI imaging is used to exclude malignant transformation or assist in diagnosis if plain radiographs are equivocal. A cartilage cap thicker than 2cm when measured with MRI is thought to be at a greater risk of undergoing malignant transformation according to Bernard et al. (Bernard SA, Murphey MD, Flemming DJ, Kransdorf MJ. Improved differentiation of benign osteochondromas from secondary chondrosarcomas with standardized measurement of cartilage cap at CT and MR imaging. Radiology. 2010 Jun;255(3):857-65. doi: 10.1148/radiol.10082120. Epub 2010 Apr 14. PMID: 20392983). and therefore, if morbidity is acceptable, would be considered for surgical excision.
    CONTRAINDICATIONS
    In asymptomatic lesions, treatment is not indicated. Excision may be warranted in large lesions where local pressure effects may occur or in adults where the risk of malignant transformation warrants removal.

    Setup

    Anaesthesia:
    General anaesthetic with single dose pre-operative IV antibiotic prophylaxis (we use Flucloxacillin and Gentamicin).
    Tranexamic acid single dose pre-operatively.
    Positioning:
    Lateral position with pressure area cushioning for contralateral shoulder, elbow, knee. Carter Bain arm support for the operative limb.
    Theatre:
    Ultra-clean Howarth ventilated theatre and canopy.
    Equipment:
    Cautery, suction, general orthopaedic set, oscillating saw/osteotomes, drains, sutures.
    Thromboprophylaxis:
    TED stockings for six weeks (unless contraindications), chemical prophylaxis until mobile.

    Operation – 1

    Pre-operative radiographs reveal a large (O) osteochondroma arsing from the right scapula in a patient with established HME (Hereditary multiple exostoses). We can see other osteochondromas in the ipsilateral proximal (H) humerus in the metaphyseal region.

    Axial CT highlights that in the plane at least it would seem feasible to preserve the glenoid and coracoid process and thus perform a sub-total scapulectomy, which is associated with improved function. We can easily identify the (H) humerus, (S) scapula and (O) osteochondroma in this imaging plane. This image is the most useful for mentally planning the surgery: we need to remove the tumour en-bloc whilst preserving the glenoid and (C) coracoid process to maximise function. It is clear that we need to dissect between the thoracic cage and axilla and the tumour to remove it and osteomomise the scapula between the glenoid and the tumour.

    The coronal CT highlights that the (O) osteochondroma lies adjacent to the thoracic cavity and will be a major resection.

    Again the bulk of the (O) osteochondroma is highlighted by the pre-operative CT. Also visualised are the (C) clavicle, (L) lung and (R) ribs which appear to be flattened rather than domed due to the pressure effect of the osteochondroma during skeletal development.

    The patient is positioned such that the entire forequarter is accessible anteriorly and posteriorly.The patient is positioned left side down, right side up with the arm supported using a Carter Braine support, under an appropriate anaesthesia with IV antibiotics at induction. Two U-drapes are used to isolated the entire forequarter, ensuring that we have draped beyond the midline spinous processes of the cervical, thoracic and lumbar spine. We need to move the arm during the procedure to improve access around the scapula and so having the arm draped free is an advantage. I have annotated the presumed anatomical locations of various periscapular muscles that we need to identify and divide: these include (T) trapezius, (L) levator scapulae, (R) rhomboids, (LD) latissimus dorsi, (TM) teres major, (Tm) tees minor, (I) infraspinatus and (S) supraspinatus.

    Alcoholic Chlorhexidine (70%) is used twice to cleanse the skin of the exposed shoulder, axilla and arm. The exclusion drapes are imperative to ensure that the alcohol doesn’t seep elsewhere and cause chemical irritation.

    Incisional Ioban drapes are applied to the skin and the forearm is isolated from the surgical field. After sterile surgical drapes are applied, the forequarter is isolated and then incisional Ioban drapes are applied to the skin.

    Longitudinal skin incision along the mid-scapular line. A skin incision is made using a “bra strap” incision, essentially utilising a utilitarian approach from the acromioclavicular joint down to the inferior angle of the scapula. This incision can be tailored to the tumour being addressed but the ‘bra-strap’ analogy is useful when planning the incision.

    Full thickness skin flaps are elevated over the tumour to optimise wound healing. The soft tissues are very thin over the chondrosarcoma so full thickness flaps, as thick as possible, over the tumour are raised using McIndoe’s dissecting scissors, taking care to leave a wide surgical margin over the tumour. To do this, ask your assistant to maintain gentle traction on the edge of the flap to hep identify the plane for dissection with scissors (or cautery).
    As the pre-operative biopsy is unreliable in up-to two-thirds of cases of possible secondary chondrosarcomas, maintaining a healthy degree of suspicion is appropriate. Tsuda et al. described the optimal surgical resection margins in secondary chondrosarcomas of the pelvis (which is comparable to the scapula as both are central flat bone locations rather than appendicular) and concluded that in order to minimise the risk of local recurrence, that a margin of 1mm or more was sufficient for local control in such tumours (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6903848/).

    Elevate the flap laterally off the dorsal aspect of the tumour using cautery.Develop the plane and elevate the soft-tissues off the chondrosarcoma using cautery towards the lateral scapular and axilla. Maintaining the tension on the skin flap using Lane’s soft-tissue holding forceps, aids this step, as shown in the photograph. It is likely that the skin edges will be trimmed later so tissue damage from the forceps is unlikely to be an issue.

    Using McIndoe’s scissors and cautery, the medial skin flap is elevated Repeat the same process medially towards the spinous processes, which reveals the sizable chondrosarcoma. Dissection continues until the medial and lateral borders of the scapular are palpable. Preserving full-thickness flaps is essential to optimise wound healing.

    The full thickness soft issue flap is now medial to the tumour, so we now start to encounter more normal anatomy, including the (T) trapezius and (R) rhomboids. The anticipated location of these muscles is annotated.

    It is worth reminding oneself at this point about the superficial musculature (left side of image) and deeper musculature (right side of image) that will be encountered using a posterior approach to the scaplua.

    Release the superior portion of trapezius inserting onto the (SS) scapula spine.Having identified (using palpation) the (SS) spine of the scapular, the superficial muscle inserting superiorly is the trapezius. This is divided off the scapula spine using cautery as shown over the Mcindoe’s dissecting scissors to delineate the scapular spine. Trapezius acts to retract, depress and elevate the scapula; it arises from the occiput, nuchal ligament and spinous processes of C7 to T12 and inserts onto the scapula spine, lateral clavicle and acromion.

    Identify the suprascapular fossa containing supraspinatus.Having divided the insertion of the (T) trapezius of the scapular spine, the (SF) suprascapular fossa containing the supraspinatus muscle is encountered, cranial to the (R) rhomboids and levator scapulae.
    The superficial muscles inserting onto the medial border of the scapula, from proximal to distal are levator scapulae, rhomboid minor and then rhomboid major. Deep to these, inserting onto the anteromedial border is serratus anterior. Serratus anterior has nine ‘slips’ arsing from the first to eighth ribs (the 2nd rib has two ‘slips’) and has superior, middle and inferior parts which act to pull the scapula forward on the thoracic cage. Innervated by the long thoracic nerve (of Bell), damage to which during surgery in the axilla (e.g. breast lymph node clearance) is a common cause of scapula ‘winging’.

    Divide the residual trapzius muscle distally as it inserts onto the medial border of the scapula spineHaving identified the plane deep to trapezius, continue to release muscle inserting onto the scapula from cranial to caudal. I do this by digitally inserting my index finger beneath the muscle because this means I can instantly palpate my surgical resection margin off the tumour and maintain tension during muscle division.
    Trapezius, which has three parts (superior, middle, inferior) arises from the occiput, nuchal ligament and along the cervical and thoracic vertebral spinous processes (variable level caudally e.g. T4-12 origin). Trapezius is applied by the spinal accessory nerve (cranial nerve XI) which also supplies the sternocleidomastoid muscle, both or which are commonly tested during examination of the cranial nerves; trapezius ‘shrugs’ the the shoulders by elevating and abducting the scapula.

    Identify the medial border of the scapula deep to levator scapulaeIdentify the medial border of the scapula, which is deep to the levator scapulae muscle and start to divide the levator off the medial border of the scapula from cranial to caudal using cautery. You need to palpate the medial border and ask the assistant to move the scapula around to confirm where to dissect, which is why the arm is draped free. Levator arises from the spinous processes C1-4 and inserts onto the superior angle and medial border of the scapula (deep to trapezius).

    Divide the rhomboids off the medial border of the scapulaHaving divided the levator scapulae, next divide the rhomboids off the medial border of the scapula, which lie immediately caudal to the levator. Aside from a subtle adventitial layer, it is difficult to isolate the division between levator and the separate rhomboids. The rhomboids have a two portions, the minor which is cranial and the major which is caudal. the rhomboids arise from the spinous processes of C7-T1 and T2-5 respectively and act to stabilise the scapulothoracic articulation and draw the scapula medially and superiorly.

    Divide the rhomboids of the medial border of the scapulaUsing your assistant to elevate the (T) tumour and scapula laterally off the thorax, divide the superficial (R) rhomboids inserting onto the medial border of the scapula. Distal to the scapula spine (previously identified) the superficial muscles inserting onto the scapula are levator scapulae and the rhomboids, which all need to be divide to excise the scapula. The rhomboids and levator scapulae are innervated by the dorsal scapular nerve (C5) arising from the brachial plexus, which medialise and stabilise the scapulothoracic articulation; injury to the dorsal scapular nerve causes ‘winging’ of the scapula and as the nerve pierces the middle scalene is associated with inter-scalene blocks and hypertrophy of the middle scalene muscle in bodybuilders.

    Identify the plane deep to rhomboid majorNext identify the plane inferior to (RM) rhomboid major, here visualised as the change in the plane at the (IA) inferior angle of the scapular where we can see the fat and fascial layer of the chest wall. Also visualised is the (SA) serratus anterior which inserts onto the medial scapula deep to the rhomboids.

    This plane is developed so that we can now identify the fat and fascia off the chest wall deep to the rhomboids major.I have completed the division of (RM) rhomboids major revealing more of the fat deep to the muscles before the chest wall and serratus are encountered.

    Divide the serratus anterior off the medial border of the scapula from caudal to cranialDevelop the plane deep to serratus anterior and divide the muscle as it inserts onto the medial border of the scapula using cautery; this is the deepest part of the dissection and will dramatically improve exposure and access to the tumour. I prefer to do this digitally and thus you can palpate the edge of the tumour at the time of dividing the muscle to ensure a wide resection margin is maintained.
    Serratus anterior is supplied by the long thoracic nerve (of Bell), which arises from the brachial plexus and is vulnerable during surgery for breast cancer when performing axillary node clearance and is consequently the most common cause for winging of the scapula.

    Continue to release all of the muscle off the medial border of the scapula Continuing the dissection of the peri-scapular muscles medially also develops the plane between serratus anterior (deep) and subscapularis (superficial) which contains the suprserratus bursa.

    Divide the omohyoid off the superior angle At the superior of the scapular, we next divide the omohyoid muscle off the superior angle of the scapula; the omohydoid depresses the hyoid bone and is innervated by the ansa cervicalis of the cervical plexus.

    Dissect out supracsapularis muscle to preserve some initiation of abductionWe now dissect the supraspinatus muscle and release it from of the supraspinatus fossa by dissecting between the supraspinatus muscle and the spine of the scapular, in an attempt to preserve the muscle for some later function after surgery. The supraspinatus is innervated by the suprascapular nerve (C5-6), a branch of the upper trunk of the brachial plexus, which travels through the suprascapular notch.

    Operation – 2

    Dissect suprascapularis out of the supraspinatus fossaContinue to divide the muscle attachment of the supraspinatus to the supraspinatus fossa to mobilise the supraspinatus muscle.

    Having dissected through the muscle, try to identify the suprascapular nerve (C5,6) as it enters the supraspinatus fossa, having travelled from the brachial plexus dorsally through the suprascapular canal.

    Scapular notchDeep to the supraspinatus muscle is the scapular notch which contains the (SSN) suprascapular nerve (C5-6) travelling dorsally to supply the supraspinatus and infraspinatus muscles.
    Having identified the suprascapular nerve, protect this to preserve muscle function for supraspinatus. We will attempt to osteotomise through the suprascapular notch in order to save the nerve, at the end of the procedure.
    The scapular canal, through which the nerve traverses, is formed by the base of the coracoid process of the scapula and the suprascapular ligament. The vascular supply to the supraspinatus muscle is slightly variable, but typically the artery and vein pass superficial to the suprascapular ligament (separate from the nerve).

    Moving distally to the inferolateral angle of inferior and lateral aspect of the scapular, we now divide the very broad latissimus dorsi as it inserts onto the scapula over artery forceps using cautery.

    Divide latissimus dorsiLatissimus dorsi, beloved of plastic surgeons, is a very broad and flat muscle that performs extension and adduction of the glenohumeral joint.

    Isolate and divide teres major off the inferior angle of the scapula By gently elevating the scapular out of the wound, we can now identify the (TM) teres major, which arises from the lateral border of the scapular and can be seen lying deep to the cut (LD) latissimus dorsi annotated in the photograph.

    Divide teres major, leaving some muscle on the tumour as a surgical margin.

    Having divided latissimus dorsi, develop the plane between subscapularis and the thoracic cage. Having divided the rhomboids and latissimus dorsi muscles, we can now elevate the scapular off the thoracic cage and we can see that the tumour has left a thickened bursal layer which is a useful plane to identify and follow when dissecting the scapula away from the thorax. We can see also on the deep surface of the scapula, the tumour is covered by the subscapularis muscle, which arises from the medial border of the scapular and travels to the front of the humerus inserting on to the lesser tuberosity. The residual serratus anterior remains covering the the thoracic cage and ribs, but the thickened bursal layer has developed due to years of irritation from the tumour on this adventitial layer.

    Develop the adventitial plane between the subscapularis muscle and the chest wall using cautery, by having the assistant lift the tumour out of the wound towards the humerus.

    The deep dissection of the procedure is now completed and the scapular and tumour is now very mobile and only a few more peri-scapular muscles need dividing plus the osteotomy need to be performed.

    Identify and isolate the teres minor muscle.I prefer to use an artery clip placed under the muscle which is typically well rounded (teres = round) in order to isolate and maintain tension during division using cautery. Teres minor is part of the rotator cuff musculature inserting onto the humeral greater tuberosity and acts as an external rotator of the humerus. It is innervated by the posterior branch of the axillary nerve.

    Divide teres minor off the lateral border of the scapula

    Divide Infraspinatus muscle in the infraspinatus fossaAgain using an artery clip, the entire muscle is isolated and kept under tension to divide the muscle using cautery. There are no anatomical structures at risk during this step.

    Insert retractors ventral to the scapula prior to osteomisingPrepare for the osteotomy. Insert bone levers as retractors deep to the scapular at the site of the proposed osteotomy, which is well away from the main tumour and the more superior retractor is placed into the suprascapular notch to protect the nerve and preserve the nerve to supraspinatus.
    Theoretically, the contents of the axilla are at risk during the osteotomy but the retractors are placed deep to the scapula and superficial to the subscapularis muscle, which acts as additional protection. The contents of the axilla are the axillary artery and vein and their branches, the brachial plexus and lymph nodes.

    Using a 1.27mm oscillating saw blade, divide the scapular by osteotomising the scapular through the (IF) infraspinatus fossa and through the (SS) scapular spine.The retractor in the (SN) scapular notch is poorly visualised due to the divided supraspinatus muscle, but aids protection of the suprascapular nerve exiting the scapula notch.

    The osteotomy is now completed keeping a small portion of the residual scapular and glenoid and coracoid process.

    Deep to the site of the osteotomy lies the subscapularis muscle, which needs to be divided to complete the resection.Subscapularis forms the posterior border of the axilla, along with teres major and latissimus dorsi. The medial border is serratus anterior, anterior border pectoralis minor and major, medial border is the humerus, biceps and coracobrachialis and superior border is the clavicle, subclavius muscle and first rib. The subclavius lies between the rib and clavicle.

    Remove the tumour and scapula The specimen is submitted for histology to evaluate the resection margins to confirm that a wide en-bloc resection has been performed which minimises the risk of local recurrence. A minimal resection margin of 1mm is thought to minimise the risk of local recurrence of peripheral chondrosarcomas of the pelvis according to Tsuda et al. (Tsuda Y, et al. Is the width of a surgical margin associated with the outcome of disease i patients with peripheral Chondrosarcoma of the pelvis? Clinic Orthop Relat Res 2019 Nov; 477(11): 2432–2440. doi: 10.1097/CORR.0000000000000926). The pelvis and scapula are both axial flat bone disease sites and considered analogous in oncological terms.

    The tumour is placed on the back table prior to submission to the laboratory for analysis. Here we can see that close but adequate surgical margins have been maintained around the tumour.

    We can see how thin the scapular is and can identify the osteotomised bone and infraspinatus fossa.

    Pulse lavage is used to irrigate the wound to remove any clot prior to wound closure.

    The infraspinatus and supraspinatus residual muscles are sutured together using 2.0 Vicryl to reduce dead space and minimise bleeding.

    Two surgical drains are placed in the wound between the more superficial muscle layer and the deep chest wall layer, which has the potential for a large dead space and haematoma/seroma to collect.

    Distally we close the muscle layer by approximating the rhomboids to the cut edge of the latissimus dorsi as shown.

    The muscle repair is now complete and the dead space has been closed by opposing all of the peri-scapular muscles together.The eight peri-scapular muscles include the rotator cuff muscles (supraspinatus, infraspinatus, teres minor and subscapularis), trapezius, serratus anterior, levator scapulae, and rhomboids minor and major. This does not include the extrinsic muscles originating from the coracoid process of the scapula (short head of biceps and coracobrachialis, pectorals minor), the supraglenoid tubercle (long head of biceps), infraglenoid tubercle (long head of triceps), and lateral scapula spine (posterior deltoid).
    Additionally the ligaments related to the coracoid process include:
    the coracoclavicular ligament(s) (formed by the conoid (lateral) and trapezoid (medial) ligaments to the clavicle
    the coracoacromial ligament
    the coracohumeral ligament
    and the superior transverse scapular ligament (to the suprascapular notch)

    Operation – 3

    Superficial closure using interrupted 2.0 vicryl.

    Any residual excessive skin is now trimmed to optimise wound healing.You could consider excising an ellipse of skin with the tumour to avoid this step, but if misjudged you risk a tight skin closure. Using the Lane’s soft-tissue holding forceps, grasp excessive skin and elevate off the thorax to demarcate where to incise the excessive skin.

    A running undyed 0 Vicryl suture is used to approximate the skin edges.

    Subcuticular closure using 3.0 Monocryl.

    Incisional vacuum dressing and dressings for the drains are applied.

    This post-operative radiograph highlights that the glenoid, coracoid and acromion have been preserved as per the pre-operative plan.

    Post Operative

    HDU overnight for observation.
    VAC dressing to be removed 7 days and wound reviewed (this is the longest our tissue viability team will allow vacuum dressings to remain without being changed)
    Removal of drains when less than 50mls over 24 hours.
    Analgesia and dietary supplements.
    Contact patient with results of histology when available.
    Keep sling in place for 2 weeks for pain relief then begin passive circumduction exercises and progress to active movements by 4-6 weeks.

    Recommended Reading

    The most common primary malignant bone tumours involving the scapula are chondrosarcomas and Ewing’s sarcoma according to Vahanan et al. (Mayil Vahanan, N., Mohanlal, P., Bose, J.C. et al. The functional and oncological results after scapulectomy for scapular tumours: 2–16-year results. International Orthopaedics (SICO 31, 831–836 (2007). https://doi.org/10.1007/s00264-006-0261-1). Other indications may include soft-tissue sarcomas and metastatic bone disease.
    Malawer classified shoulder girdle resections into six groups depending upon whether all or part of the scapula and humerus are resected and whether the procedure involves a glenonhumeral arthrotomy or an extra-articular resection (Malawer MM, Meller I, Dunham WK. A new surgical classification system for shoulder-girdle resections. Analysis of 38 patients. Clin Orthop 1991;(267):33–44). A partial scapulectomy where the neck of the scapula and the glenoid were retained, as in this case, is classified as type II resection.
    Gibbons et al. reported function after scapulectomy for neoplasms of bone and soft tissues. In their series of 14 cases they noted that resection of 80% of the scapula had only a modest effect on function. They also noted that subtotal scapulectomy gave an excellent functional result if all or part of the glenohumeral joint could be preserved (Gibbons CL, Bell RS, Wunder JS, Griffin AM, O’Sullivan B, Catton CN, Davis AM. Function after subtotal scapulectomy for neoplasm of bone and soft tissue. J Bone Joint Surg Br. 1998 Jan;80(1):38-42. doi: 10.1302/0301-620x.80b1.8183. PMID: 9460950), which was confirmed by Vahanan et al., who reported superior functional results if the glenoid was preserved and stated that useful shoulder function may be expected if the muscles are reconstructed around the shoulder, namely the deltoid and trapezius.
    As the scapula and pelvis are considered to both represent axial, flat bone locations for primary bone sarcomas, the article by Tsuda et al. is relevant. The authors identified that local recurrence of peripheral chondrosarcomas is predicated by the surgical resection margin width. Local recurrence of chondrosarcoma is associated with inoperable tumours and death. A margin of 1 mm or more was sufficient to minimise the risk of local recurrence and is the only outcome that surgeons can influence for their patients (Tsuda et al. Is the width of a surgical margin associated with the outcome of disease in patients with peripheral chondrosarcoma of the pelvis. Clinic Orthop Relat Res 2019 Nov; 477(11): 2432–2440.doi: 10.1097/CORR.0000000000000926).

    Reference

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