Reinforcement Reconstruction using Fascia Lata Autograft for Rhomboid Paralysis-Induced Scapular Winging

Summary

Here, we present a protocol outlining a unique approach to achieving a stable scapulothoracic joint and restoring the dynamics of the rhomboid muscle.

Abstract

Scapular winging caused by paralysis of the rhomboid muscle is a relatively uncommon condition in shoulder outpatient. Despite the paucity, it presents as a debilitating condition with sequelae of poor function and deconditioning. Reinforcement reconstruction and restoring the rhomboid muscle dynamic presents a biomechanical treatment option for patients because of paralyzed rhomboids. Building upon our previous research demonstrating successful myointegration of autologous fascia lata grafts, we introduce an innovative reconstruction surgical technique utilizing these grafts to address rhomboid muscle paralysis. We performed reinforcement reconstruction using fascia lata autograft on a patient for painful scapular winging caused by paralyzed rhomboids and aimed to achieve a normal rhythm of the scapulothoracic joint. The procedure achieved functional restoration and scapular stabilization through reinforcement reconstruction. Postoperative assessment at 6 weeks revealed a full shoulder range of motion, absence of scapulothoracic discomfort, and resolution of scapular winging confirmed by clinical testing. This advancement provides shoulder orthopedic surgeons with a novel biomechanical solution for managing refractory scapular winging.

Introduction

The scapular winging was first described in 1723¹, and this disease was a rare scapulothoracic disorder characterized by altered motion and positioning of the scapula, known as scapular dyskinesis. This condition manifested as the prominence of the medial border of the scapula relative to the thorax, both at rest and during movement^2,3. Abnormal scapular motion arises from the inability of the scapulothoracic muscles to stabilize the scapula against the thorax, and potential causes included neurologic injury, soft tissue and bone abnormalities, or secondary effects from other shoulder joint disorders⁴. The principal causes of scapular winging are paralysis of the serratus anterior muscle and the trapezius muscle⁵. Much more rarely, the scapular winging may be due to rhomboid muscle paralysis⁶.

Traditional treatment measures primarily focused on conservative therapies such as rehabilitation treatments, including ultrasound therapy, transcutaneous electrical stimulation, and shoulder joint kinesitherapy⁷. However, for patients who do not respond well to these conservative treatments, surgical options like scapulothoracic fusion were eventually required. These surgeries significantly restricted the range of motion of the scapulothoracic joint and were also highly invasive.

Liao et al. found that the fascia lata autograft could fuse with the muscle very well⁸. Based on that finding, fascia lata could stabilize the scapular if it is fused with rhomboid muscles. Therefore, we performed reinforcement reconstruction using fascia lata autograft for painful scapular winging caused by paralyzed rhomboids and aimed to achieve a normal rhythm of the scapulothoracic joint (Figure 1 and Figure 2).

Protocol

This study was approved by the Ethics Committee of the First Affiliated Hospital of Army Medical University (BIIT2025060)

NOTE: The patient is a 21-year-old male presenting with right scapular pain and a disorder of mobility for over 2 years, during which conservative treatment has proven ineffective (Figure 1A). Preoperative CT scans of the patient's spine and scapula revealed no significant bony abnormalities (Figure 2A).

1. Patient preparation

1. Provide standard pre-surgical preparation. Verify the patient's information, surgical site, and allergy history.

2. Surgical preparation

1. Administer anesthesia.
   1. Evaluate the operative risk by assigning a grade based on the American Society of Anesthesiologists (ASA) classification of physical health. The ASA of this case is Grade I.
   2. Insert at least one large-bore intravenous cannula (14 G or 16 G) into a peripheral vein.
   3. Monitor the electrocardiogram, arterial pressure (via radial artery cannulation), capnography, pulse oximetry, urinary output, and body temperature.
      NOTE: The anesthesiologist manages the intraoperative anesthesia and begins to administer the anesthetic drugs after verifying the patient's information. Both inhalational and intravenous anesthetic techniques were utilized.
   4. Conduct a blood gas analysis to assess blood gas levels and pH during the surgical procedure.
2. Insert the absorbable lupine anchor into the vertebral pedicle.
   1. Position the patient in a prone orientation. Conduct routine disinfection of the surgical area, which included the patient's affected upper limb (including the entire scapula), extending upwards to the neck, downwards to the navel, and laterally to the contralateral scapula.
   2. Locat the T5 and T10 pedicles under anteroposterior and lateral fluoroscopy using the C-arm. Mark the skin accordingly.
   3. Make a skin incision approximately 1 cm in length. Bluntly dissect down to the vertebral body using a vascular clamp.
   4. Place guide devices into the T5 and T10 pedicles. Under C-arm fluoroscopy guidance, carefully insert a suture anchor into the pedicle (Table of Materials, Figure 2B, Figure 3).
3. Harvest fascia lata graft (Figure 4).
   1. Position the patient in a lateral decubitus position (Figure 4A). Beginning at 2 cm from the proximal end of the greater trochanter on the ipsilateral thigh, make a longitudinal incision through the skin and subcutaneous tissue along the lateral aspect of the femur to expose the fascia lata.
   2. Measure the distance from the medial border of the scapula to the thoracic vertebra (Figure 4B,C) and harvest approximately 18 cm in length and 4 cm in width of fascia lata from the ipsilateral thigh, then remove any residual muscle and adipose tissue from the fascia lata graft (Figure 4F,G).
   3. Resect the fascia lata graft to two 18 cm 2 cm grafts and fix the ends of the fascia lata grafts with a running whipstitch suture technique with No. 2 high-strength suture (Table of Materials).
4. Perform reinforcement reconstruction of the rhomboid major and minor muscles.
   1. Make a 2 cm incision at the medial border and inferior angle of the scapula, dissect soft tissues, and insert suture anchors (Figure 4D, E).
   2. Extend one end of the fascia lata graft using a guiding pin to the incisions at T10, then suture and secure the graft using a suture anchor. Subsequently, insert another suture anchor to fix the other end of the fascia lata graft at the inferior angle of the scapula (Figure 4H).
   3. Perform similar procedures to secure the fascia lata graft at the T5 scapular body and the intersection point between the medial edge of the scapula and the spine of the scapula (Figure 4I).
   4. After the surgery, discontinue anesthesia and safely stabilize the patient during recovery.

3. Postoperative rehabilitation

1. Maintain the affected limb in a neutral position using an abduction orthosis, which provides adequate protection while allowing a controlled active range of motion exercises for the elbow and wrist joints during the initial 6-week postoperative period.
2. Instruct the patient to perform shoulder and scapular range of motion exercises after 6 weeks, followed by strength training after 3 months.
3. After 3 months, advise the patient to engage in non-competitive shoulder strength sports activities according to their tolerance and gradually return to sports activities.

Results

At 6 weeks postoperatively, the patient had normal shoulder joint mobility, with flexion at 180°, abduction at 180°, internal rotation reaching T7, and external rotation at 75°. There was no pain or discomfort in the scapulothoracic region, and the scapular wing test showed normal results (Figure 1B, Table 1, Table 2).

Discussion

Scapular winging was most commonly associated with serratus anterior muscle paralysis, while cases caused by rhomboid muscle paralysis were relatively uncommon. The rhomboid muscle paralysis could lead to winging of the medial border and lateral rotation of the inferior angle of the scapula. Therefore, the surgery technique aimed to restore the stretch of the rhomboid muscle by reconstruction of the paralyzed rhomboid using fascia lata autograft.

Scapular winging was commonly seen in the serra...

Materials

Name	Company	Catalog Number	Comments
Absorbable Lupine anchor	DePuy Mitek	210712	For insertion into the vertebral body and scapula, and for fixation of the graft
C-shaped X-ray imaging device	General Electric Company	https://www.gehealthcare.com/zh-cn/products/surgical-imaging/oec-one-cfd	The C-arm is utilized for intraoperative pedicle localization and pedicle screw placement
Orthocord	DePuy Synthes	https://www.jnjmedtech.com/en-US/product/orthocord-high-strength-suture#jnj-64e8f507470cb
WilSuture	Rejoin Medical	800648300	For braided suture grafts