Clavicular Osteotomy Research Articles

CLAVICULAR OSTEOTOMY FOR SURGICAL EXPOSURE OF THE SHOULDER JOINT: FUNCTIONAL OUTCOMES, COMPLICATIONS, AND SURGICAL TECHNIQUE. A REGIONAL NZ EXPERIENCE

AimClavicular osteotomy was described as an adjunct to deltopectoral approach for improved exposure of the glenohumeral joint. This study aims to present contemporary outcomes and complications associated with the routine use of clavicular osteotomy by a single surgeon in a regional setting within New Zealand.MethodsA retrospective case series of patients who have undergone any shoulder arthroplasty for any indication between March 2017 to August 2022. This time period includes all patients who had clavicular osteotomy(OS) and patients over an equal time period prior to the routine use of osteotomy as a reference group (N-OS).Oxford Shoulder Score (OSS) and a Simple Shoulder Test (STT) were used to assess functional outcomes and were compared with the reported literature. Operative times and Complications were reviewed.Results66 patients were included in the study. 33 patients in the OS group and 33 in the N-OS group. No difference in age, sex, indications for operative intervention and the surgery provided was identified. No significant difference in operative time between groups (N-OS 121 minutes; OS 128 minutes).No clinically significant difference was identified in the OSS (N-OS; mean 38 vs OS 39) or the STT (N-OS 8.3 vs OS 9). The outcomes scores of both groups are in keeping with published literature.Two post operative clavicle fractures, one prominent surgical knot occurred in the OS that required further surgical intervention. Two cases of localized pain over the clavicle and one case of the prominent lateral clavicle were reported in the OS group. Two cases of localized pain over clavicle reported in the N-OS group.ConclusionUse of clavicular osteotomy is not associated with inferior patient reported. The osteotomy introduces specific risks, however, the study provides evidence that these complications are infrequent and avoidable. Surgeons should feel confident in using this adjunct when exposure to the shoulder is difficult.

Prevalence of Concomitant Distal Suprascapular Nerve Injury in Patients with Root-level Brachial Plexus Palsy: A Clinical Anatomic Study of Injury Pattern.

Root-level suprascapular nerve palsy is commonly reconstructed via spinal accessory nerve transfer in brachial plexus injury, yet some patients fail to recover. We hypothesize that this relates to concomitant undetected lesions distal to the nerve transfer coaptation. 67 patients with plexus injury and C5/6 root involvement were included in this prospective study between March 2021 and October 2022. During spinal accessory to suprascapular nerve transfer the entire suprascapular nerve was explored, via cresenteric clavicular osteotomy, and anatomic variations and injury patterns categorized. Proximal root involvement was C5-C6 (n=8), C5-C7 (n=13), C5-C8 (n=17), C5-T1(29). Mean time from injury to surgery was 5.6 months. The suprascapular nerve was found to be injured in 16/67 cases (24%). In 9 cases (13%) the lesion was proximal to the suprascapular fossa. In 3 cases (4%) the suprascapular nerve was injured both proximally and within the fossa, and in 4 cases (6%) in the fossa or distal to it. Therefore, in 7 cases (10%), a traditional suprascapular nerve transfer would not successfully bypass the zone of injury of the suprascapular nerve in the fossa. Of the 16 cases of concomitant suprascapular nerve injury, 1/8 in occurred in C5-C6 root injury, 4/13 of C5-C7 root injury, 5/17 of C5-C8 root injury and 6/39 in total paralysis. Concomitant distal suprascapular nerve injury in brachial plexus stretch palsy occurred in 24% of the cases. This warrants attention from the surgeon to identify distal lesions and to perform the nerve transfer beyond any secondary lesions.

In silico analysis of rib force distribution in postscapulothoracic arthrodesis model.

Scapulothoracic arthrodesis (STA) is carried out by fixing the scapula to thoracic ribs which in turn allows the patient suffering from Facioscapulohumeral Muscular Dystrophy to carry out shoulder-joint dependent activities of daily living. A biomechanical analysis of this procedure has not been conducted in the literature and, for the first time, this study investigates the finite element calculated glenohumeral-applied load distributions on ribs by creating a post-STA model. Three loading directions on the glenohumeral joint are designated: anterior-posterior, superior-inferior, and lateral-medial. Reaction forces on the ribs are calculated based on the glenoid force percent. Simulations are repeated by removing a singular rib contact to observe the change in force distributions in the case of missing levels or failed bonding as well as the impact of clavicle osteotomy. Total load distribution is observed highest at T2 followed by T3 and T6. In the T2 missing scenario, total loads on T3 and T4 increase. In the T4 missing case, the most affected level is T3. In the T6 missing scenario, total loads on T5 and T7 increase. In the clavicular osteotomy scenario, all levels' loads increase; the highest is recorded in T7 by 460%, followed by T5, T4, T2, T6, and T3. While all levels contribute to fixation strength, T2 is subjected to the highest loads, and, in the missing level scenarios, the loads are tolerated sufficiently by the remaining levels. Missing T4 scenario has the least effect on the system, which is interpreted as potentially the only skippable level of fixation. Clavicular osteotomy has the highest effect on the arthrodesis site.

Modified Woodward's operation combined with clavicular osteotomy in the treatment of Sprengel malformation:a case report

Modified Woodward's operation combined with clavicular osteotomy in the treatment of Sprengel malformation:a case report

THE FLAG TECHNIQUE: PEDICLED FROZEN AUTOGRAFT RECONSTRUCTION FOR SHOULDER GIRDLE SARCOMAS-A REPORT OF THREE CASES

Reconstruction of extra-articular shoulder resections is challenging. We present a novel method using the patient’s own pedicled proximal humerus and scapula, sterilized with liquid nitrogen cryoablation and recycled as an autograft. The technique was used for three patients with malignant tumors. We present the surgical technique and clinical outcomes. All patients had high-grade sarcomas of the proximal humerus requiring extra-articular resection. At surgery, the tumor-bearing shoulder girdle was exteriorized with wide margins and pedicled on the humerus via a medial scapula and clavicular osteotomy. The pedicled shoulder was then frozen in liquid nitrogen, the extraosseous tumor mass and non-viable muscle were removed and the residual shoulder girdle was re-implanted. Average follow up was 4.5 years. At the time of writing, all patients are alive without disease and have retained their original reconstructions. Scapulothoracic and elbow movements were preserved with stiff glenohumeral joints. One patient experienced an implant complication requiring surgery to remove a migrated Kirschner wire and to mesh reinforce the glenohumeral capsule. The flag technique is a reliable, low cost reconstructive option for extensive sarcomas of the shoulder girdle. A stiff glenohumeral joint with preserved scapulothoracic motion may be expected post-surgery.

Outcomes of primary repair of sternal cleft defects: Providing a "bony cover".

Sternal clefts are rare congenital anterior chest wall defects created by a lack of midline thoracic fusion. Various surgical repairs have been proposed to provide protection to underlying viscera in these defects. This study aims to perform primary sternal cleft repair using techniques, leading to the provision of a complete bony cover and to assess their outcomes on follow-ups. During 2009-2020, seven patients were referred to our unit with sternal defects. Out of them, four infants with sternal clefts underwent primary repair using bilateral perichondrial flap creation of the sternal bars and sliding costal chondrotomy at our institute. In one of them with a wider defect, bilateral "intraperiosteal" sliding clavicular osteotomy was additionally performed to achieve tension-free closure. Satisfactory surgical outcomes were achieved with an uneventful postoperative period. On follow-up, all four patients are thriving well and have a stable anterior chest wall. Those with follow-ups longer than 5 years showed evidence of bone formation. Bony cover to the heart can be provided in all varieties of sternal cleft defects using primary surgical repair early in infancy. The delay in surgical correction increases the complexity of the procedure and may require the use of prosthetic material which has its own disadvantages.

Clavicular osteotomy to assess subclavian vein injury during internal fixation of midshaft clavicle fractures.

Midshaft clavicle fractures are commonly fixed with locking plates. The subclavian vein risks injury during this procedure and the consequences can be fatal. The purpose of this present study is to describe a clavicular osteotomy technique in order to equip orthopaedic surgeons with a means of rapidly accessing a subclavian vein injury. The osteotomy should only be performed following an urgent intraoperative vascular surgery assessment. There must be shared consensus from both orthopaedic and vascular surgery that direct repair of the subclavian vein is necessary, and further exposure is required. The results of the technique performed on thirteen embalmed cadaveric specimens are also included. The osteotomy was able to expose 3.16 cm (SD = 0.60) of the subclavian vein and both the fracture and osteotomy site of all clavicles (100%) were able to be reduced and fixed using a single pre-contoured fifteen-hole lateral plate intended for use on the contralateral shoulder. This surgical technique study confirms that in the rare circumstance that the osteotomy is utilized, adequate exposure of the subclavian vein is achieved.

Bilateral Sprengel’s Deformity Treated with the Modified Woodward Procedure: Technique and Outcome of 3 Consecutive Case Reports

Sprengel’s deformity is a congenital anomaly characterized by a hypoplastic and elevated scapula that results in cosmetic and functional impairment. In this study, we report the results of 3 severe cases of bilateral Sprengel’s deformity with associated Klippel-Feil syndrome treated by the modified Woodward procedure. Between 2013 and 2015, 3 patients of a mean age of 5.4 years were diagnosed with bilateral Sprengel’s deformity and associated Klippel-Feil syndrome. All the shoulders were graded as Cavendish 4 and had a bar connecting the scapula with the cervical vertebrae. Patients were managed surgically with the modified Woodward procedure and a clavicular osteotomy. The mean follow-up time was 62 months. No intraoperative or postoperative complications were recorded and all patients remained neurologically intact. The average improvement of the abduction of the shoulders was 30° and the mean lowering of the scapula was 2.6 cm. All patients improved by at least 1 Cavendish grade. The modified Woodward procedure is a reliable and effective technique to improve shoulder cosmesis and function even in severe cases of bilateral Sprengel’s deformity with associated Klippel-Feil syndrome.

Clavicular osteotomy in complicated revision of total shoulder arthroplasty: indications, surgical technique, and outcomes.

Adequate exposure in revision of total shoulder arthroplasty (TSA) is important for optimal prosthesis placement and functional results. A clavicular osteotomy in difficult cases of revision TSA is a useful surgical technique that increases the superior exposure area, provides safer dissection, minimizes damage to the anterior deltoid muscle, improves glenoid access, and allows for superior dislocation of the humeral component. There is a paucity of literature analyzing the clavicular osteotomy during challenging cases of revision TSA. The aims of this study were to describe the application, surgical technique, and outcomes of revision TSA with a clavicular osteotomy. This was a retrospective study of consecutive patients who underwent revision TSA with a clavicle osteotomy at a single institution (2004-2016). A curved longitudinal clavicular osteotomy is created parallel to the origin of the anterior deltoid muscle. This allows for lateral reflection of the osteotomy and anterior deltoid muscle to significantly increase superior exposure and reduce damage to remaining deltoid muscle fibres. Osteotomy closure is simple with four or five Nice knot osteosutures. The Constant-Murley score and osteotomy healing were assessed at every follow-up. All complications were reviewed. Forty patients who had a mean age of 63.8years (range 37-87) at time of surgery and mean follow-up duration of 34months (range 12-88) were analyzed. Pre-operative Constant-Murley scores improved significantly from 32 ± 19.0 to 58 ± 15.0 (p < 0.001) at oneyear and 65 ± 13.1 (p < 0.001) at twoyears. Primary osteotomy healing and callus formation were evident in 95% of cases by threemonths. Five patients developed post-operative complications (13%) related to the clavicular osteotomy: three mid-diaphyseal clavicular fractures sustained after trauma (8%), one clavicular stress fracture (3%), and case of one loosening (3%). Three patients (8%) required surgical revision of the osteotomy (two internal fixation and one revision osteosuturing). No neurovascular injuries or scapular fractures were encountered. A curved longitudinal clavicular osteotomy is beneficial in difficult revision TSA and is another tool in the arsenal of experienced shoulder surgeons who manage these challenging cases. This surgical technique increases glenoid exposure, facilitates superior dislocation of the humeral component, minimizes anterior deltoid damage, and reduces the risk of neurovascular injuries. All clavicular complications occurred within fourmonths prior to osteotomy union, with many sustained due to trauma. However, patients who developed a complication had comparable shoulder function as those without.

Results of surgical treatment for Sprengle's deformity with vertical corrective scapular osteotomy.

IntroductionSprengle deformity is the most common congential anomaly of shoulder complex that is the result of scapular placement in cephalad abnormal position. The purpose of this study is the evaluation of clinical and radiological results of vertical corrective scapular osteotomy and comparision of these results with previous studies.MethodsWe retrospectively reviewed the results of the vertical corrective scapular osteotomy (VSO) with or without clavicular osteotomy and wake-up test in 31 consecutive patients at an average duration of follow up of 30 month (6 month-15 years). 22 patients were girls and 9 were boys. The average age of the patients was 7.3 years (3-13) at the time of surgery. We evaluated the clinical and radiological results of this method in last fallow-up. No funding was used for this study and there are no conflicts of interest.Results31 surgical procedures were performed. All osteotomies were healed. No neurovascular complication. Postoperative the mean shoulder flexion and abduction were improved 30 and 36° respectively (p < 0.001). The mean improvement of superior scapular angle (S.S.A) and inferior scapular angle (I.S.A) were 16 and 21° respectively (p < 0.001).ConclusionIt is intuitive that more cosmetic scapular lowering with little chance of neurovascular problems can be achieved after VSO. In addition, scapular rotation can be corrected using this technique, which should be considered as one of the advantages of this technique.We believe that a properly applied VSO procedure in severe deformities is safe with predictable outcomes in the treatment of a complex deformity that provides favorable functional and cosmetic outcomes in the longer term.

Chronic anterior sternoclavicular instability: technique and results of corrective clavicular osteotomy

Chronic anterior sternoclavicular (SC) instability is a rare but potentially disabling condition. It can arise in conjunction with trauma or hyperlaxity, or both. Numerous surgical techniques have been described, but no gold standard exists. SC instability is often position-dependent and can be reduced with the arm in a specific position. To directly address this issue, we used a technique of corrective osteotomy of the clavicle with the goal to reorient the articular portion of the medial end of the clavicle so that it remains stable in all functional positions of the arm. To illustrate the technique and the correction in space, we performed postoperative 3-dimensional computed tomography analyses of the shoulder girdle of 4 patients. Clinical scores were obtained at the final follow-up and compared with preoperative scores. Mean follow-up was 64 months (range, 19-191 months). The mean Constant score improved from 58 (range, 45-68) preoperatively to 73 (range, 69-84) postoperatively and the Subjective Shoulder Value from 42 (range, 15-80) to 79 (range, 50-100). All patients reported good or very good stability of the SC joint at the last follow-up. We recorded no intraoperative or direct postoperative complications. During follow-up, 3 patients underwent removal of the plate, 1 of them for plate breakage. The mean postoperative correction for combined rotations is given as a 3-dimensional angle and averaged 28.0° (range, 8.6°-39.7°). In this pilot study, medial corrective clavicular osteotomy using the described technique treated anterior SC instability with improvement of clinical shoulder function scores and good patient satisfaction. The technique appears simple and safe and deserves further evaluation.

Sprengel Deformity and Omovertebral Bone

Abstract: Sprengel deformity is the most common congenital abnormality of the shoulder girdle, resulting from an elevated, dysplastic, and variably fixed scapula. It has cosmetic implications that make it readily identifiable, and may be also associated with functional impairment. It may associate with other structural abnormalities, such as the presence of an omovertebral bone, or bar. When present, it adds to the immobility of the scapula. We present the images relating to the case of a 8-year old boy, with previous history of spina bifida and hydrocephalus. He presented with scapular elevation and limitation of shoulder motion, and was diagnosed with a Cavendish 4 type Sprengel deformity of the scapula. An associated omovertebral bone connecting the superomedial angle of the scapula and cervical spine was detected on CT scan. 3D reconstruction of the images allowed accurate definition of the deformity and the relations of the abnormal bone. The deformity was afterwards surgically treated, by means of a clavicle osteotomy, omovertebral bone resection, and Woodward procedure. The patient had an eneventful recovery, and had satisfactory functional and cosmetic gains.Case Presentation An 8-year old boy, previously surgically treated for hydrocephalus and spina bifida, was referred to our Paediatric Hospital for evaluation of the fixed elevation and limited motion of the right shoulder (Figure 1). A clinical diagnosis of Sprengel Deformity was made, being a Cavendish 4 grade [1] in severity. In the investigations ordered scapular elevation was confirmed and the presence of an anomalous omovertebral bone was noted between the superomedial angle of the scapula and C6 spinous process (Figure 2). Surgery was proposed, and a clavicular osteotomy, omovertebral bone resection and Woodward procedure were performed (Figure 3). Sprengel Deformity is a complex congenital pectoral girdle deformity, with cosmetic and functional implications. It is associated with other deformities, such as spinal dysraphism (as spina bifida in this case), scoliosis, and rib and vertebral segmentation abnormalities, such as Klippel-Feil. [2] The omovertebral bone is an anomalous bone connecting the elevated scapula to the cervical spine, being called omovertebral bar should it be fused between them. It contributes to the immobility of the scapula and the functional impairment, and its resection should be performed if surgical treatment is pursued [1]. It may not be always visible on plain x-rays, and so more advanced imaging is recommended prior to surgery for assessment and planning, such as CT (ideally with 3D reconstruction) [3]. Clavicle osteotomy is advised either in the treatment of associated clavicle deformity, or as to lower the chances of brachial plexus injury [4] in higher grade corrections.The child in the case described had an uneventful postoperative course, and received rehabilitation treatment, having later satisfactory functional and cosmetic gains. Conclusion: Sprengel deformity is a complex shoulder girdle abnormality. If surgical treatment is considered, associated abnormalities such as the omovertebral bone should be sought - CT scan with 3D reconstruction is advised. When found, omovertebral bone should be excised during surgery

Interscapulothoracic (forequarter) amputation for malignant tumors involving the upper extremity: surgical technique and case series

Forequarter amputation (FQA) is reserved for large, multifocal, or recurrent tumors affecting the shoulder and upper extremity. Although it is performed less frequently with the advancement of limb salvage surgery, FQA remains an important treatment in select patients. The purpose of this study is to illustrate the surgical technique in a case series of 4 patients. Between 2010 and 2012, 4 patients (mean age, 61 years; range, 36-78 years) presented with malignant disease of the upper extremity that was not amenable to or had failed limb salvage. All patients had FQA by the illustrated anterior clavicular osteotomy technique. Patient data were retrospectively reviewed from preoperative workup until last follow-up or death. All patients had tumors that involved major neurovascular structures of the upper extremity and shoulder girdle. One presented with neuroendocrine carcinoma and has achieved local control after FQA. Three presented with high-grade sarcoma. One of these had recurrence after prior limb salvage and neoadjuvant radiation and unfortunately succumbed to metastatic disease 6 months after FQA. An additional sarcoma patient who presented after shoulder arthroscopy for a "labral cyst" with recurrent and fulminant synovial sarcoma succumbed to her disease. The remaining sarcoma patient has had no recurrence and minimal phantom pain at last follow-up. Obtaining vascular control early in the procedure is crucial to minimize blood loss. When it is indicated, FQA is a relatively safe and reliable procedure for dealing with otherwise challenging tumors of the shoulder girdle and upper extremity. Level IV, case series, treatment study.

Combined ipsilateral neck and axillary lymphadenectomy for metastatic skin cancers: A case series and surgical tips

In the absence of distant disease simultaneous skin cancer metastasis to neck and axillary lymph nodes necessitates both an axillary and neck en block lymphadenectomy. Acombined ipsilateral neck and axillary lymph node dissection should involve an in-continuity dissection through the cervicoaxillary canal for optimal lymphatic and oncological clearance. Review of the literature reveals little published instruction on the procedure since the radical surgery performed by Bowden over 50 years ago. We present 4 cases where ipsilateral axillary and neck lymph node dissections were performed for metastatic melanoma and a case of apical axillary node dissection via a neck incision approach. Our surgical tips include performing apical axillary node dissection via the neck incision and consideration of clavicular osteotomy or clavicular excision. A transclavicular approach was taken in one patient who had an excellent functional outcome after a plate and screw fixation. One elderly patient required a middle third claviculectomy which reduced shoulder elevation but was not associated with functional impairment. We conclude the surgery is safe and associated with the usual morbidity ascribed with either an axillary or neck dissection undertaken in isolation. However, patients have a significant risk of disease relapse as would be expected due to the duel metastatic sites, multiple lymph node and neck involvement which are known to be independent poor prognostic factors on melanoma survival and relapse.

Surgical Technique: Simple Technique for Removing a Locking Recon Plate With Damaged Screw Heads

The introduction of locking plates in the treatment of periarticular fractures was a major breakthrough in orthopaedic evolution. Removal of these implants is extremely difficult as a result of cold welding and stripping of screw heads. A 31-year-old man had a schwannoma of the left C5-C6 nerve roots and upper trunk of the brachial plexus. One year before presentation he had undergone excision of the lesion through an approach using a clavicular osteotomy. The osteotomy had been fixed with a titanium locking recon plate. While surgically removing the implant, only one screw could be removed. The remaining five screws could not be turned owing to cold welding; repeated attempts at removing the screws damaged the screw heads. A large bolt cutter was used to cut the plate between the holes, and the resulting rectangular sections with the screws then were unscrewed from the bone. Limited literature is available regarding techniques for locking screw removal. These include using a carbide drill bit or diamond-tipped burr, high-speed disc, or conical extraction screw. Not all centers have specialized instruments such as carbide drill bits to remove screw heads, but a large bolt cutter usually is available when screws cannot be unscrewed owing to cold welding. The technique of cutting is easily reproducible and does not require additional soft tissue stripping.

An Approach to the Supraclavicular and Infraclavicular Aspects of the Brachial Plexus

The surgical approach to the brachial plexus is of great importance during surgery for brachial plexus injuries--obstetric or traumatic. A number of different approaches have been described over the years for these injuries, with each 1 having its own advantages and disadvantages. We describe a novel approach to the supra-clavicular and infra-clavicular aspects of the brachial plexus, which has been used by senior author successfully for the past 15 years. It involves creation of 2 windows, 1 above and 1 below the clavicle in case of adult traumatic plexus injuries. A slight variation of joining the 2 incisions and creation of a laterally based cervicopectoral flap is used for obstetric brachial plexus injuries along with the use of clavicular osteotomy. The advantages of this approach are that it gives rapid access to the brachial plexus; wide exposure can be obtained for all regions of the plexus and donor nerves such as the spinal accessory nerve can be harvested in the same incision.

Outcome of Mears procedure for Sprengel’s deformity

Background:Sprengel’s shoulder is characterized by scapular maldescent and malposition, causing restriction of shoulder and cervical spine movements. It is associated with a variety of other congenital anomalies. Various surgical procedures have been described to treat this anomaly with no consensus as to the surgical procedure of choice. We report the results of the Mears procedure in the treatment of Sprengel’s shoulder.Materials and Methods:Seven children between the age group of two and six years were treated for Sprengel’s deformity, with omovertebral bar, and other congenital anomalies. The Cavendish score and Rigault radiological score were used to assess the severity of the deformity, and the position of the scapula relative to the cervical spine, respectively. The Mears procedure involved scapular osteotomy, par tial scapular excision, and release of a long head of triceps. Clavicular osteotomy was done only in two cases to decrease the risk of traction injury to the brachial plexus. Postoperatively, the patients were immobilized in a shoulder sling and range of motion exercises were started as early as possible. The patients were followed regularly at six weeks, three months and regularly at six-months interval.Results:The mean improvement in flexion and abduction was 45 ° (40 – 70 °) and 50 ° (40 – 70 °), respectively, which was the combined glenohumeral and thoracoscapular movement. The cosmetic and functional improvement by this procedure was acceptable to the patients. Minor scar hypertrophy was seen in two cases.Conclusion:The Mears procedure gives excellent cosmetic and functional results. This procedure addresses the functional aspect of the deformity and is much more acceptable to the patient and parents.

Surgical Correction of Severe Sprengel Deformity to Allow Greater Postoperative Range of Shoulder Abduction

Although the Sprengel deformity is relatively uncommon, several surgical procedures have been described for its treatment. In this article, we will report the outcome of a certain surgical technique targeted at the management of children with severe Sprengel deformity. The technique aims to increase their postoperative range of shoulder abduction. We reviewed the results of 15 shoulders operated in 11 patients. The children had severe congenital elevated scapula (9 Cavendish IV and 6 Cavendish III) and were all with less than 90 degrees of preoperative shoulder abduction. The mean age at surgery was 64 months, the mean length of follow-up was 36.5 months, and the mean age at the last examination was 95 months. Surgery included fixation of the upper scapula to the lower thoracic spine. As such, we used a stout suture with lateral displacement of the inferior tip of the scapula and immediate postoperative mobilization with physiotherapy. None of the children underwent clavicular osteotomy. Operative results were evaluated on both functional and cosmetic bases. Appearance improved according to the Cavendish scale. Postoperatively, 7 shoulders were graded as Cavendish I and the other 8 as Cavendish II. The range of motion improved significantly by comparing the preoperative and postoperative range of abduction. The mean for postoperative abduction was 139 degrees, with an absolute range of 90 to 170 degrees. Three shoulders had winging of the scapula. There was temporary postoperative upper arm numbness in 1 shoulder. Four patients had a cosmetically unattractive scar because of keloid formation. All families were satisfied with the results (9 very good and 6 good). We have described a procedure for severe Sprengel deformity up to 15 years of age followed by immediate physiotherapy. This procedure not only results in the caudal displacement of the scapula, but it also corrects the scapular and glenoid plane (with limited procedures). Accordingly, it offers an improvement, both functionally and cosmetically. Level IV therapeutic study.

Long-Term Results of Modified Green Method in Sprengel's Deformity

Congenital undescended scapula (Sprengel deformity) is a rare deformity that is reported in the literature mostly as small case series with short- or medium-term follow-up periods. Here, we aimed to present the long-term results of this deformity treated with modified Green procedure. The modified Green procedure was performed in 24 patients (28 shoulders) with Sprengel deformity. Clavicular osteotomy accompanied in all, and omovertebral bone excision in 13 shoulders. The mean age of the patients at the time of surgery was 4.5years (range 1.5-17years). Mean follow-up period was 11years 4months (4.3-17years). Preoperative cosmetic appearance was noted as Cavendish III in 17 shoulders and as IV in 11 shoulders. In addition to the Cavendish scale, shoulder abduction, shoulder asymmetry, and scapular elevation and medialization were evaluated. The decrease in scapular elevation and Cavendish scale, and the improvement in shoulder abduction and scapular medialization postoperatively were statistically significant (P<0.001). Cosmetic improvement of at least one Cavendish grade were attained in 88.9% of shoulders. One patient (unilateral) who was Cavendish grade IV preoperatively died in the early postoperative period from unrelated causes. Of the remaining 10 preoperatively grade IV shoulders, 2 remained at the same grade, 1 improved to grade III, and 7 shoulders to grade I. Of the 17 preoperatively grade III shoulders, 1 shoulder stayed the at same grade, 7 shoulders improved to II, and 9 shoulders to grade I. Postoperative winging in 2 shoulders and hypertrophic scarring in 6 shoulders were noted. The modified Green procedure is a relatively safe and reliable method in the treatment of severe Sprengel deformity cases and provides highly constructive and aesthetic results in the long term.

UNUSUAL OSTEOCHONDROMA OF THE MEDIAL PART OF THE CLAVICLE CAUSING SUBCLAVIAN VEIN THROMBOSIS AND BRACHIAL PLEXOPATHY

Benign primary bone tumors, including osteochondromas, rarely occur in the clavicle. We report an atypical case in which an osteochondroma developed in the medial part of the clavicle and caused thoracic outlet syndrome with primary subclavian vein thrombosis (Paget-Schroetter syndrome), brachial plexus paresthesias, and mechanical sternoclavicular pain in an otherwise healthy young man. To our knowledge, we are the first to report a case of thoracic outlet syndrome that was caused by an osteochondroma of the medial part of the clavicle. The two other medial clavicular tumors that have been reported in the literature were asymptomatic1,2. We present the natural history of this lesion and report the outcome after local excision through a clavicular osteotomy followed by internal fixation. We also discuss clavicular embryology and speculate on the pathoanatomic origin of a medial clavicular osteochondroma. The patient and his family were informed that data concerning this case would be submitted for publication. A sixteen-year-old male high-school student who worked part-time as a butcher presented to a vascular surgeon with a six-week history of insidious swelling in the left, non-dominant arm. The patient also complained of diffuse brachial plexus paresthesias. He smoked one pack of cigarettes per year but was otherwise healthy. A laboratory evaluation for thrombophilia revealed normal findings. The family history was negative for hereditary bone tumors and thromboembolism. A venogram revealed complete occlusion of the left subclavian vein along with adjacent partial obstruction of the axillary vein. Increased collateral venous drainage was present, suggesting external compression. This finding was consistent with a primary subclavian thrombosis resulting from thoracic outlet syndrome, also known as Paget-Schroetter syndrome. Routine radiographs of the chest were initially interpreted as normal, although a later retrospective review ultimately revealed the lesion. Magnetic resonance images of the shoulder revealed no obvious extrinsic …