1. Scapulothoracic Endoscopy for the Painful Snapping Scapula: Endoscopic Anatomy and Scapuloplasty Technique 
Deepak N. Bhatia, M.S.(Orth), D.N.B.(Orth) 
Arthroscopy Techniques 
Volume 4, Issue 5, Pages e551-e558 (October 2015)
DOI: /j.eats
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

2. Fig 1
Overview of chicken-wing position and external anatomic landmarks. The draping should extend medially to the thoracic spinous processes (dotted line). Inferior (I) and superior (S) scapular portal sites (x) are marked. An additional superior portal (B) is shown for reference and is not used in this technique. The superomedial space (SM, black arrow) and subspinous space (white arrow) are shown. (INF, inferior; ip, inferior scapula pole; LAT, lateral; MED, medial; SC, scapula; sp, scapular spine; SUP, superior.)
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

3. Fig 2
(A) The inferior scapular portal (I) is placed 2 to 3 cm medial to the medial scapular border (SC). The sheath (Ar) is directed superiorly toward the superomedial space (SM) and slightly ventral to avoid penetration of the supraserratus space. The inset shows the insufflation of the subspinous space with saline solution for distention prior to portal incision. Lateral pressure is applied by the surgeon to make the medial border prominent. (B) The superior scapular portal is placed 4 cm superior to the inferior scapular portal and 2 to 3 cm medial to the medial scapular border. The portal should not be placed above the scapular spine (SP). The probe (Pr) is passed through the superior scapular portal for blunt dissection. The inset shows the insufflation of the superomedial space with saline solution for distention prior to portal incision. Lateral pressure is applied by the surgeon (H) to make the medial border prominent. (AR, arthroscope sheath; ip, inferior scapula pole; S, superior scapular portal.)
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

4. Fig 3
The first anatomic landmark to be identified in the infraserratus space is the serratus anterior muscle (SRA). The probe (PR) is used to palpate the muscle and the superomedial angle (SUP), and blunt dissection is used to clear the bursa (BS). The subspinous space is inferior (INF), and the chest wall (CH) forms the floor of this space. The viewing portal is the inferior scapular portal, and the working portal is the superior scapular portal, with a 30° view.
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

5. Fig 4
(A) Bursectomy is performed with a radiofrequency probe passed through the superior (S) portal cannula (Cn), and the arthroscope (Ar) is in the inferior (I) portal. A spinal needle (N) is passed in the region of the superomedial angle (SM) for orientation. (B) Superomedial space bursectomy is performed with the radiofrequency probe (RF) facing away from the chest wall (CH). The bursectomy extends from the superomedial angle (SMA) down to the subspinous bursal curtain (CT). The viewing portal is the inferior scapular portal, and the working portal is the superior scapular portal, with a 30° view. (INF, inferior; LAT, lateral; MED, medial; SC, scapula; SRA, serratus anterior; SUP, superior.)
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

6. Fig 5
(A) The second anatomic landmark is the subspinous bursal curtain (CT), and excision of this bursal thickening shows the subspinous space (asterisk). The serratus anterior (SRA) forms the roof of this space, and the chest wall (CH) is at the floor. (B) Complete excision of the bursal curtain permits visualization of the subspinous space adhesions (SSS). (C) Scapular vessels (AR) are present in the subspinous space and are seen coursing through the bursal tissue and toward the serratus anterior. The viewing portal is the inferior scapular portal, and the working portal is the superior scapular portal, with a 30° view. (in, inferior; RF, radiofrequency probe; SMA, superomedial angle; sp, superior.)
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

7. Fig 6
(A) A rare aberrant serratus anterior superior (SRA) is seen completely covering the superomedial scapular angle (SMA). The superior 2 cm of the aberrant attachment should be excised to permit a clear view of the superomedial corner. (B) The prominent bony Luschka tubercle (TL) is exposed by excision of soft tissue superior to the serratus anterior. The superomedial scapular tip (asterisk) is the third anatomic landmark; this is located using an outside-in spinal needle (N) and demarcates the medial (M) and superior (Su) borders. The viewing portal is the inferior scapular portal, and the working portal is the superior scapular portal, with a 30° view. (b, bursa; CH, chest wall.)
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

8. Fig 7
(A) The tubercle of Luschka is seen prior to tuberoplasty. Excision of the soft tissue over the tubercle (TL) and in the superomedial space is completed with a shaver (SH), and the spinal needle (N) is used for orientation. (B) Tuberoplasty is performed with a motorized PoweRasp (PW), and the Luschka tubercle (TL) is thinned out until it is flush with the surrounding bone. The viewing portal is the inferior scapular portal, and the working portal is the superior scapular portal, with a 30° view. (CH, chest wall; SRA, serratus anterior.)
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

9. Fig 8
(A) Measured resection for scapuloplasty involves burring the medial border (M; black arrows) and the superior edge (SU; white arrows) of the superomedial scapular angle. (B) The thinned-out tubercle (TL) is further burred to complete the resection. The fascial layer of the periscapular muscles (white arrows) is preserved and is continuous with the borders of the superomedial angle (black arrows). The viewing portal is the inferior scapular portal, and the working portal is the superior scapular portal, with a 30° view. (BR, motorized burr; TL, Luschka tubercle.)
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions

10. Fig 9
Reversal of the portals permits visualization (CAM) of the resection area and subspinous region through the superior scapular portal (S; viewing portal). The area can be probed (PB) through the inferior portal (I; working portal). The adequacy of resection and presence of debris can be assessed. (in, inferior; LAT, lateral; N, spinal needle; Su, superior.)
Arthroscopy Techniques 2015 4, e551-e558DOI: ( /j.eats )
Copyright © 2015 Arthroscopy Association of North America Terms and Conditions