Scapular fixation in muscular dystrophy

BACKGROUND: Winging of the scapula is caused by weakness of the thoracoscapular muscles, which allows the scapula to lift off the chest wall during shoulder movements. In facioscapulohumeral muscular dystrophy (and occasionally in other muscular dystrophies) there is selective weakness of the thoracoscapular muscles which may spare other shoulder muscles such as the deltoid muscle. This imbalance results in significant winging and loss of shoulder function. Historically, a number of different surgical and non-surgical interventions have been used to achieve scapular stability. This review examines the evidence available for the use of all scapular fixation techniques in muscular dystrophy, especially facioscapulohumeral muscular dystrophy. OBJECTIVES: To examine the evidence for the relative efficacy of scapular fixation techniques in muscular dystrophy (especially facioscapulohumeral muscular dystrophy) in improving upper limb function. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (20 July 2009), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2009) Medline (1966 to July 2009) and EMBASE (1980 to July 2009) for randomised trials. We also contacted authors of trials and other experts in the field. SELECTION CRITERIA: All reports of scapular fixation for muscular dystrophy, including quasi-randomised or randomised controlled trials, comparing any form of scapular fixation (surgical and non-surgical) in people (of all ages and of all severity) with scapular winging due to muscular dystrophy. Our primary outcome measure was objective improvement in shoulder abduction. Our secondary outcome measures were: patient-perceived improvement in performance of activities of daily living, cosmetic results, subjective improvement in pain and proportion of patients with significant postoperative complications. DATA COLLECTION AND ANALYSIS: We collated and summarised studies on the treatment of scapular winging in muscular dystrophy. MAIN RESULTS: No randomised trials were identified. We therefore present a review of the non-randomised literature available. AUTHORS' CONCLUSIONS: There is no evidence from randomised trials to support the suggestion from observational studies that operative interventions produce significant benefits. However, these have to be balanced against postoperative immobilisation, need for physiotherapy and potential complications. We conclude that a randomised trial would be difficult, but a register of cases and the use of a standardised assessment protocol would allow more accurate comparison of the disparate techniques.