Modified Green operation

Modified Green surgery is used for the surgical treatment of congenital high shoulder scapula. Congenital high shoulder scapula is an uncommon deformity. It was first reported by Sprengel in 1891, so it is also known as Sprengel malformation. This malformation is the result of incomplete reduction of the scapula. The scapula is a limb bud around the cervical spine during the embryo, and the embryo begins to gradually descend to the upper part of the thorax at the end of the third month. For some unknown reason, the scapula does not fall or fall. Forming a high shoulder scapular deformity, it is also known as congenital scapular bone insufficiency. Malformations are unilateral or bilateral, but are common on one side. Common pathological changes include changes in bone and muscle. The position of the scapula is 3 to 10 cm higher than the healthy side, and some of the scapula are almost in contact with the occipital bone. The scapula is more small than the healthy side, the transverse diameter is widened, the medial and inferior horns are moved inward, even close to the spinous process, and the upper part is bent forward and hooked beyond the top of the thorax. In addition, often combined with congenital thoracic scoliosis, cervical and thoracic vertebral body, wedge-shaped vertebral body, spina bifida, atlas and occipital fusion, short neck, rib absent, rib fusion, cervical rib, clavicular malformation or dysplasia. Muscle changes can be seen as missing or completely absent from one or more of the scapular muscles. The lower part of the trapezius muscle may be absent or weak, and the rhomboid muscle and the levator scapula are often underdeveloped or partially fibrotic. About one-third of the patients have a fiber bundle, cartilage or bony connection between the inner upper corner of the scapula and the spinous process, lamina or transverse process of the lower cervical spine. The cartilage or bony is called the omovertebral bone, a piece of rhomboid cartilage and bone plate, located in a strong fascia sheath. Sometimes a good joint can be formed between the shoulder blade and the shoulder vertebrae, sometimes with only the fibrous tissue of the shoulder blade, and rarely a strong bone beam connecting the spine and the shoulder blade. The main clinical manifestations were the high position of the affected scapula and the restricted upper extremity of the affected side. There are generally no other serious dysfunctions. In terms of treatment, the deformed person does not need surgery, and can perform active and passive functional exercises to improve the upper limb abduction and high lift. Severe cases can be operated on. Because congenital high shoulder scapularity is not simply an increase in the scapula, it often combines with other malformations and more severe soft tissue contractures, so the surgical outcome is not ideal, and the recovery is not level. However, if handled properly, significant results can be achieved. Surgical treatment should consider the following factors: 1 Age of surgery: It is generally believed that more than 3 years old can not tolerate such corrective surgery; 3 to 6 years old surgery is better; the sooner the surgery is better after 3 years old. In older patients, the surgical outcome is poor, and brachial plexus tension can occur. Children under 3 years old and over 6 years old are not absolute surgical contraindications. The patient should be determined according to the general condition of the patient and the degree of deformity. 2 The degree of deformity and dysfunction: the deformity is not obvious, the function is not affected, and there is no need for surgery; Severe side deformity, appearance and function of the greater impact, surgery should be performed; 3 deformity of the side: bilateral symmetry deformity without surgery; 4 combined with other deformities: other abnormalities, severe surgery, such as combined with other visceral abnormalities Such as congenital heart disease. The surgical methods for the treatment of congenital high shoulder scapula include scapular upper and shoulder vertebral bridge resection, major scapula resection and scapula scapula. The first type of surgery is mainly suitable for older scapula scapula. The patient, the operation is relatively simple, can partially improve the appearance and function, but can not achieve the purpose of the scapula bone migration; the second type of scapula after the major resection of the function and appearance are greatly affected, is not used now; the third type of scapula bone down Surgery is the main surgical procedure for the treatment of such malformations. There are many methods, but Green surgery and Woodward surgery are commonly used. The latter kind of surgery is clear, the method is simple, the bleeding is small, and the effect is good, which should be the first choice. The development of the scapula of congenital high shoulder scapula is small. When the scapula is moved down, the lower plane of the scapula cannot be controlled by the lower scapula of the healthy side, but only the lower scapula is required to move to the same level. It is prone to overcorrection or brachial plexus tension. Treatment of diseases: congenital high shoulder scapula Indication Modified Green surgery is suitable for patients with unilateral high shoulder scapula of 2 to 7 years old. Contraindications 1. The age is too small, the general condition is poor, and the patient cannot tolerate the operator. 2. Consolidate other serious deformities. 3. The deformity is light, the function is not significant, or the bilateral symmetry of the shoulder is high. 4. The skin of the surgical area has infected lesions. Preoperative preparation 1. Detailed examination of the general condition, pay attention to the presence or absence of other malformations, visceral dysplasia and neurological function are accessible. 2. Matching blood 400~600ml. Surgical procedure Incision Beginning at the 1st finger width above the center of the scapula, do all the mouth parallel to the scapula, inward to the upper edge of the scapula, and then bend downwards, 1 finger wide from the medial edge of the scapula, parallel to the distal 5cm of the lower scapula. 2. Cut off the muscles, remove the upper part of the scapula and the vertebral bridge Cut the subcutaneous, deep fascia, free and retract the flaps on both sides. The free edge of the trapezius muscle is pulled inward and upward, and the trapezius muscle is exposed in the scapula, and the periosteum is freed and cut off. The muscle cutting edge is marked with a suture for later suturing (the same is done after the other muscles are cut). Turn the trapezius muscle inward to reveal the scapula, large rhomboid, small rhomboid, and supraspinatus. Separate through the periosteum, free and outwardly flip the supraspinatus to the lateral scapular notch, carefully avoiding damage through the scapular cut into the subscapular nerve and the scapular transverse artery. After the periosteum is separated and the large rhomboid muscle, the small rhomboid muscle and the scapular muscle are removed. Push back the upper edge of the scapula, and start from the inside, and open the upper part of the subscapularis muscle outside the periosteum of the scapula. Protect the superior scapular nerves and blood vessels, along the scapula, use the osteotome or bone to remove the upper part of the scapula, until the scapular notch, including the periosteum, and then remove the vertebral bridge or the connected fiber bundle outside the periosteum. Similarly, the serratus muscles were cut off from the medial edge of the scapula outside the periosteum. 3. Move and pull the wire to fix the shoulder blade When the lower angle is removed, the latissimus dorsi muscle on the spinous process is cut and cut down to the lowermost part of the trapezius muscle. Cut off the fibers of the latissimus dorsi attached to the scapula. A blunt dissociation at the deep upper edge of the latissimus dorsi makes a pocket-like gap to accommodate the lower scapula. Remove the solid fiber band from the lower corner of the shoulder blade to the chest wall to allow the shoulder blade to move down sufficiently. Then drill a hole in the base of the junction between the inner 2/3 and the outer 1/3 of the scapula, and use a 90cm thick thick steel wire to cross the hole, and pull the wire to make the ends of the wire under the shoulder blade and the gangue. Behind the muscles, through the latissimus dorsi deep into the subcutaneous side of the third lumbar vertebrae, the part made a 3cm incision, revealing the third lumbar spinous process, and passing the wire through the shallow part of the spinous process and then out the skin. Move the scapula down to the desired site, and place the lower corner in the pocket of the deep latissimus dorsi and tighten the wire. 4. Re-sew the muscles Keep the position of the scapula down, and re-sew the muscles as follows: suture the supraspinatus to the scapula. Sewing the serratus muscle, according to the natural pulling direction of the fiber to the new part of the scapula. Using the same principle, suture the scapula, large rhomboid and small rhomboid muscles, and if necessary, extend the scapula. Later, the lower part of the trapezius muscle fiber is sewed to the scapula, 2 to 3 cm away from the original attachment, so that the tension is increased below and inside, which helps the scapula to remain in a new position. Then sew the upper part of the trapezius muscle to the inner 2.5cm of the original point, which will lengthen the fibers above the muscle. The cut latissimus dorsi muscle is then placed over the distal side of the trapezius muscle and re-sewed to the normal position of the spinous process. If necessary, the latissimus dorsi can be placed in the higher position of the spinous process to better cover the subscapular horn. The upper edge of the latissimus dorsi is sutured to the lower margin of the trapezius muscle. 5. Stitching Rinse the wound, completely stop bleeding, layered suture. complication Brachial plexus Brachial plexus tension is the most serious complication of surgical treatment of congenital high shoulder scapula, mostly caused by older age, severe deformity or excessive correction. When surgery is performed in patients with severe age, severe deformity, or signs of brachial plexus paralysis found after surgery, the occlusion of clavicle should be performed. From the outside of the chest lock joint 1.5cm to the acromioclavicular joint 1.5cm to make a long incision, subperiosteal peeling, revealing the clavicle. Cut 2 cm of the clavicle from each end and cut into small pieces. These small pieces are placed in the periosteal tube, and the periosteal tube and the subcutaneous and skin are sutured. Take the prone position and do the scapula surgery. 2. Winged shoulder Due to the extensive dissection of the trunk to the scapula muscles, especially the anterior serratus and the subscapular angle of the iliac crest and the removal of the fiber bundle, if the re-attachment is not performed well, the wing-like shoulder deformity may occur after surgery. The lower scapula should be buried in the deep latissimus dorsi. The muscle should be cut in the newly adjusted area to prevent this complication. 3. Excision of the upper part of the scapula and the regeneration of the shoulder vertebrae Should adhere to the principle of periosteal operation, the removal of bone should include the periosteal resection, it can prevent resection of bone regeneration. 4. Fixed wire fracture and skin compression necrosis The wire should be thick enough to not perform shoulder abduction and excessive bending before pulling the wire. The button for pulling out the wire is larger, and the gauze under the button is thick enough.