This live surgery recording features Dr. Anthony A. Romeo performing a Scapulothoracic Fusion on a 34-year-old female patient with Facioscapulohumeral Muscular Dystrophy (FSHD).

Below is a comprehensive breakdown of the surgical procedure and case details, structured without time stamps:

1. Patient Profile and Case Background

• Patient: A 34-year-old female suffering from FSHD, a rare genetic muscle disorder that severely impacts the muscles of the face and the shoulder girdle.
• Prior Interventions: The patient previously underwent a long thoracic nerve decompression and a pectoralis major transfer to address severe left-sided scapular winging. Neither procedure was successful because the underlying disease had caused her serratus anterior muscle to entirely degenerate into non-functional, white scar tissue.
• Surgical Objective: Perform a definitive scapulothoracic fusion to structurally anchor the shoulder blade (scapula) to the rib cage, resolving the winging and restoring stable arm elevation.

2. Surgical Approach and Exposure

• Incision: A vertical incision is made along the medial (inner) border of the scapula, spanning from just above the spine of the scapula down toward the inferior angle.
• Tissue Dissection: Dr. Romeo dissects through the subcutaneous tissues to reach the muscular layers. He notes that the trapezius muscle is severely thin and atrophied due to the patient's muscular dystrophy.
• Hardware Removal: During the approach, a small plate and sutures from her previous soft tissue procedure are encountered at the lower edge of the scapula and carefully extracted.
• Muscular Releases: The origins of the supraspinatus and infraspinatus muscles are carefully elevated from the scapula to gain structural access to the bone. To allow the scapula to sit flat against the rib cage, approximately 3 centimeters of the subscapularis and serratus anterior muscle tissue are resected along the medial border.

3. Rib and Scapular Bed Preparation

• Rib Exposure: Dr. Romeo counts down the rib cage to locate ribs 3, 4, 5, and 6. The intercostal muscles over these ribs are cleared back about 3 centimeters to create a clean, vascularized bone bed for the fusion.
• Sub-Rib Tunneling: Special curved elevators are carefully passed underneath the borders of each of the four ribs. This isolates the ribs while safely protecting the underlying parietal pleura (lung lining), intercostal nerves, and blood vessels.
• Decortication: A high-speed burr is lightly used to prepare the active bony surfaces of both the thin scapula and the exposed ribs, ensuring optimal conditions for bone healing.

4. Bone Grafting and Structural Fixation

• Bone Graft Harvest: Autologous bone graft is harvested from the patient's posterior superior iliac crest (hip bone). The cavity is packed with bone wax and thrombin-soaked gel foam to minimize postoperative hematoma and hip pain.
• Fixation Strategy: A contoured 5-hole plate is placed along the infraspinatus fossa of the scapula. Heavy-duty FiberTape cerclage tapes are passed around ribs 3, 4, 5, and 6 and looped through the plate and scapula holes.
• Reinforcement: An 18-gauge surgical wire is added at the critical transition zone of the fourth rib and the scapular spine to act as a secondary mechanical backup and a structural marker.
• Biologic Augmentation: The harvested iliac crest bone graft is mixed with synthetic chips and Bone Morphogenetic Protein (BMP) before being layered directly into the fusion interface between the scapula and the ribs.
• Tensioning: The shoulder blade is manually reduced into its optimal anatomic position alongside the erector spinae muscles. The FiberTape lines are systematically tensioned to approximately 50 to 60 Newtons using a specialized mechanical tensioner and locked with half-hitch knots.

5. Intraoperative Tests and Pain Management

• Pleural Integrity Test: The surgical cavity is filled with saline, and the anesthesiologist delivers a positive pressure breath (PEEP). Dr. Romeo checks for bubbles to ensure the lung lining was not penetrated during sub-rib passing; no leaks are detected.
• Intercostal Blocks: Local anesthetic is injected directly under the borders of each involved rib to numb the intercostal nerves and reduce immediate post-surgical pain.
• Pain Catheter Placement: An erector spinae plane catheter is threaded next to the spine to deliver a continuous local anesthetic drip, supplementing the patient's pre-operative interscalene block.

6. Layered Closure and Postoperative Strategy

• Muscle Reattachment: The rhomboids, trapezius, and cuff muscles are securely repaired back over the construct using heavy Ethibond sutures to restore soft tissue coverage. The skin is closed with a running subcuticular stitch and protected with specialized dressings.
• Hospital Stay: The patient typically recovers in the hospital for 3 days to monitor for any potential pulmonary complications.
• Rehabilitation Restrictions: For the first 6 to 8 weeks, formal physical therapy is strictly forbidden. While hand, wrist, and elbow movements are encouraged, the shoulder must remain strictly supported in a sling. If the arm is allowed to hang, gravity can pull the healing scapula forward, causing it to fuse incorrectly and permanently limiting future elevation.
• Prognosis: Solid bony fusion is expected within 6 to 8 weeks, allowing a return to standard daily activities by 3 months. Final functional improvements and motion gains continue to mature up to a full year post-surgery.