TECHNICAL STRATEGY
Arthroscopic Surgical Treatment for Neglected Congenital Muscular Torticollis in Adults Bangtuo Yuan, MD,*† Feng Qu, MD,* Gang Zhao, MD,* Jiangtao Wang, MD,* Xuezhen Shen, MD,*† and Yujie Liu, MD* Background: Congenital muscular torticollis (CMT) is the third most common congenital musculoskeletal anomaly. The efficacy of surgical treatment of neglected CMT after skeletal maturity in adults remains controversial. The aim of this retrospective study was to determine the efficacy of arthroscopic release of the sternocleidomastoid (SCM) muscle for the treatment of neglected CMT in adult cases. Methods: From April 2008 to July 2013, a total of 20 adult patients (9 men and 11 women) with a mean age of 23.0 years were surgically treated for neglected CMTwith local anesthesia. The SCM muscle and clavicle were preoperatively marked. Through an artificial lacuna, an arthroscope and a radiofrequency probe were inserted. The sternal and clavicular attachments were dissected and divided via radiofrequency. Clinical evaluation was assessed using a modified Cheng and Tang score. Results: The operation was successfully completed in all the patients. Follow-up examinations from 12 to 40 months in the 20 patients showed complete muscular release and satisfactory cosmetic appearance with no recurrence. There was no evidence of serious complications. The neck scars were no longer visible after several weeks. According to the modified Cheng and Tang scale, 11 patients displayed an excellent result and 9 patients had a good result. Conclusions: Arthroscopic release of the SCM muscle with local anesthesia is a simple and effective way to surgically manage neglected CMT without any risk for either damage to the neurovascular structures or leaving visible scars. Key Words: Torticollis, sternocleidomastoid, arthroscopy, local anesthesia (J Craniofac Surg 2015;26: 512–515)
C
ongenital muscular torticollis (CMT) is a painless condition in which the sternocleidomastoid (SCM) muscle is shortened on the affected side, thereby leading to ipsilateral tilt and contralateral rotation of the face and chin.1 It is the third most common congenital musculoskeletal anomaly.2 The etiology remains unclear, although various theories have been proposed, such as the occurrence of
From the *Department of Orthopedics, Chinese People's Liberation Army General Hospital, Beijing; and †Medical School of Nankai University, Tianjin, China. Received July 20, 2014. Accepted for publication September 13, 2014. Address correspondence and reprint requests to Yujie Liu, MD, Department of Orthopedics, Chinese People's Liberation Army General Hospital, 28th Fuxing Rd, Haidian District, Beijing 100853, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001327
512
compartment syndrome at birth or intrauterine, intrauterine crowding, fibrosis from peripartum bleeding, as well as primary myopathy of the SCM and traumatic delivery.3,4 Congenital muscular torticollis can be managed conservatively before the patient is 1 year old. When the patient is between the ages of 1 and 4 years, it is well accepted that surgical treatment yields the best outcome.5–8 However, the efficacy of surgical treatment of neglected CMT after skeletal maturity in adults remains controversial. Ling5 has stated that operative treatment is of little value after skeletal maturity and may lead to additional complications. However, some surgeons have reported good clinical outcomes after the treatment of neglected CMT in adults.9–12 Traditional surgical approaches including biterminal open tenotomy,13 partial resection of the SCM muscle,14 multiple Zplasties,11 and unipolar dissection of the SCM muscle15 are reliable methods, but they produce visible scars on the exposed neck or clavicular area. Moreover, the resulting scar can be aesthetically displeasing, particularly if the incision spreads or becomes hypertrophied or keloid. Therefore, we aimed to solve this problem using a minimally invasive surgical technique under arthroscopic guidance. In this article, we reported our clinical experience with the treatment of CMT in adults and evaluated the efficacy of arthroscopic surgery in neglected cases. This technique could provide direct access to the fibrous heads without risk for damage to the neurovascular structures of the neck and an excellent cosmetic result without visible scars.
MATERIALS AND METHODS Patients We retrospectively examined all patients who underwent surgical release of the SCM with local anesthesia under arthroscope for neglected CMT between April 2008 and July 2013 in our department. All surgical procedures were performed by a single surgeon. The study was approved by the institutional review board of our hospital, and all patients were informed about the purposes of the study and gave their written consent. The patients were diagnosed on the basis of the characteristic appearances, including a persistent head tilt, a 0.5- to 1.3-cm difference in the distance from the paropias to the ipsilateral corner of the mouth, and a palpable tight band within the SCM on the affected side. Congenital anomalies of the cervical spine, spasmodic neck tilting caused by neurogenic factors, and ocular origin torticollis were excluded. A total of 20 patients (9 men and 11 women) were included in this study. Eleven patients had right-sided torticollis, and 9 patients presented with left-sided torticollis. The mean age of the patients was 23.0 years (range, 18–34 y).
Surgical Technique and Postoperative Care The patients were positioned supine with a pillow under their neck. The patients turned their head to the contralateral side and
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Arthroscopy for Adults' Neglected CMT
TABLE 1. Scoring of Overall Results (Modified From Cheng and Tang Scoring System)
Overall Results
FIGURE 1. A, Picture showing the location of the SCM muscle and clavicle as well as 2 incisions (a for arthroscope and b for motorized shaver or radiofrequency device). B, A combination of lidocaine and epinephrine injection to the incision. C, Two-portal technique in the arthroscopic approach.
retained head hypsokinesis. After marking the position of the SCM and 2 incisions (Fig. 1A), we performed the operation with 2 incisions and the distal insertion of the SCM infiltrated with local anesthetic (60 mL of a 2:1 mixture, 0.9% physiological saline with 2% lidocaine, added 0.2 mL of 0.1% epinephrine) (Fig. 1B). We used a 2-portal technique to perform the operation. A 5-mm incision was made at 10 cm inferior of the clavicle along with the medioclavicular line, approximately 2 to 3 cm anterior and medial to the axillary fold. A subcutaneous working space of 3 cm 5 cm between the middle one third of the clavicle and sternoclavicular joint was made using blunt dissection with a periosteal elevator. A 5-mm trocar was inserted for a 30-degree 4-mm arthroscope, and isotonic sodium chloride solution (containing 1-mg adrenaline per 3000-mL isotonic sodium chloride solution) was then injected constantly. This reduces bleeding during the procedure and ensures that the surgical field remains clear. Next, the other incision was made at 10 cm inferior of the sternoclavicular joint for a motorized shaver and a radiofrequency device (ArthroCare Corporation; shaft size of 3.0 mm, angle of 50 degrees, and mode of cut or coagulate) (Fig. 1C). Under arthroscopic guidance, we used the motorized shaver to debride the connective tissue attachments, thereby exposing the affected SCM (Fig. 2A). The radiofrequency device was then introduced through the same portal and sectioned the distal insertion of the SCM at the surface of the sternum and clavicle (Fig. 2B). For the recognition and release of the muscle, it was beneficial when the patients lifted their head to tighten the SCM during the procedure. Good hemostasis was maintained throughout the entire surgery to allow for a clear observation of the surgery and prevent hematoma formation after the operation. This was achieved by coagulation of any bleeding point using radiofrequency energy, increasing the pressure of the saline inflow, and supplementing the saline solution with adrenaline. Care was taken to assess for additional restricting bands and active bleeding. There was no need for a neck collar for the patients after the operation. The patients were educated on appropriate stretching
FIGURE 2. Arthroscopic view during the procedure. A, Exposing the affected SCM. B, Sectioning the affected SCM using the radiofrequency device.
Excellent
Good
Fair
Poor
(3 Points)
(2 Points)
(1 Point)
(0 Points)
6–10 6–10 Mild
11–15 11–15 Moderate
>15 >15 Severe
Rotational deficit, degrees ≤5 Lateral flexion deficit, degrees ≤5 Craniofacial asymmetry No (no, mild, moderate, severe) Scar (no, mild, moderate, severe) No Residual contracture No (no, lateral, clavicular, sternal) Head tilt (no, mild, No moderate, severe) Subjective assessment Excellent (cosmetic and functional) Overall scores 17–21
Mild Lateral Mild
Moderate Severe Lateral, Clavicular, clavicular sternal Moderate Severe
Good
Fair
Poor
12–16
7–11
Arthroscopic Surgical Treatment for Neglected Congenital Muscular Torticollis in Adults Bangtuo Yuan, MD,*† Feng Qu, MD,* Gang Zhao, MD,* Jiangtao Wang, MD,* Xuezhen Shen, MD,*† and Yujie Liu, MD* Background: Congenital muscular torticollis (CMT) is the third most common congenital musculoskeletal anomaly. The efficacy of surgical treatment of neglected CMT after skeletal maturity in adults remains controversial. The aim of this retrospective study was to determine the efficacy of arthroscopic release of the sternocleidomastoid (SCM) muscle for the treatment of neglected CMT in adult cases. Methods: From April 2008 to July 2013, a total of 20 adult patients (9 men and 11 women) with a mean age of 23.0 years were surgically treated for neglected CMTwith local anesthesia. The SCM muscle and clavicle were preoperatively marked. Through an artificial lacuna, an arthroscope and a radiofrequency probe were inserted. The sternal and clavicular attachments were dissected and divided via radiofrequency. Clinical evaluation was assessed using a modified Cheng and Tang score. Results: The operation was successfully completed in all the patients. Follow-up examinations from 12 to 40 months in the 20 patients showed complete muscular release and satisfactory cosmetic appearance with no recurrence. There was no evidence of serious complications. The neck scars were no longer visible after several weeks. According to the modified Cheng and Tang scale, 11 patients displayed an excellent result and 9 patients had a good result. Conclusions: Arthroscopic release of the SCM muscle with local anesthesia is a simple and effective way to surgically manage neglected CMT without any risk for either damage to the neurovascular structures or leaving visible scars. Key Words: Torticollis, sternocleidomastoid, arthroscopy, local anesthesia (J Craniofac Surg 2015;26: 512–515)
C
ongenital muscular torticollis (CMT) is a painless condition in which the sternocleidomastoid (SCM) muscle is shortened on the affected side, thereby leading to ipsilateral tilt and contralateral rotation of the face and chin.1 It is the third most common congenital musculoskeletal anomaly.2 The etiology remains unclear, although various theories have been proposed, such as the occurrence of
From the *Department of Orthopedics, Chinese People's Liberation Army General Hospital, Beijing; and †Medical School of Nankai University, Tianjin, China. Received July 20, 2014. Accepted for publication September 13, 2014. Address correspondence and reprint requests to Yujie Liu, MD, Department of Orthopedics, Chinese People's Liberation Army General Hospital, 28th Fuxing Rd, Haidian District, Beijing 100853, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001327
512
compartment syndrome at birth or intrauterine, intrauterine crowding, fibrosis from peripartum bleeding, as well as primary myopathy of the SCM and traumatic delivery.3,4 Congenital muscular torticollis can be managed conservatively before the patient is 1 year old. When the patient is between the ages of 1 and 4 years, it is well accepted that surgical treatment yields the best outcome.5–8 However, the efficacy of surgical treatment of neglected CMT after skeletal maturity in adults remains controversial. Ling5 has stated that operative treatment is of little value after skeletal maturity and may lead to additional complications. However, some surgeons have reported good clinical outcomes after the treatment of neglected CMT in adults.9–12 Traditional surgical approaches including biterminal open tenotomy,13 partial resection of the SCM muscle,14 multiple Zplasties,11 and unipolar dissection of the SCM muscle15 are reliable methods, but they produce visible scars on the exposed neck or clavicular area. Moreover, the resulting scar can be aesthetically displeasing, particularly if the incision spreads or becomes hypertrophied or keloid. Therefore, we aimed to solve this problem using a minimally invasive surgical technique under arthroscopic guidance. In this article, we reported our clinical experience with the treatment of CMT in adults and evaluated the efficacy of arthroscopic surgery in neglected cases. This technique could provide direct access to the fibrous heads without risk for damage to the neurovascular structures of the neck and an excellent cosmetic result without visible scars.
MATERIALS AND METHODS Patients We retrospectively examined all patients who underwent surgical release of the SCM with local anesthesia under arthroscope for neglected CMT between April 2008 and July 2013 in our department. All surgical procedures were performed by a single surgeon. The study was approved by the institutional review board of our hospital, and all patients were informed about the purposes of the study and gave their written consent. The patients were diagnosed on the basis of the characteristic appearances, including a persistent head tilt, a 0.5- to 1.3-cm difference in the distance from the paropias to the ipsilateral corner of the mouth, and a palpable tight band within the SCM on the affected side. Congenital anomalies of the cervical spine, spasmodic neck tilting caused by neurogenic factors, and ocular origin torticollis were excluded. A total of 20 patients (9 men and 11 women) were included in this study. Eleven patients had right-sided torticollis, and 9 patients presented with left-sided torticollis. The mean age of the patients was 23.0 years (range, 18–34 y).
Surgical Technique and Postoperative Care The patients were positioned supine with a pillow under their neck. The patients turned their head to the contralateral side and
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 26, Number 2, March 2015
Arthroscopy for Adults' Neglected CMT
TABLE 1. Scoring of Overall Results (Modified From Cheng and Tang Scoring System)
Overall Results
FIGURE 1. A, Picture showing the location of the SCM muscle and clavicle as well as 2 incisions (a for arthroscope and b for motorized shaver or radiofrequency device). B, A combination of lidocaine and epinephrine injection to the incision. C, Two-portal technique in the arthroscopic approach.
retained head hypsokinesis. After marking the position of the SCM and 2 incisions (Fig. 1A), we performed the operation with 2 incisions and the distal insertion of the SCM infiltrated with local anesthetic (60 mL of a 2:1 mixture, 0.9% physiological saline with 2% lidocaine, added 0.2 mL of 0.1% epinephrine) (Fig. 1B). We used a 2-portal technique to perform the operation. A 5-mm incision was made at 10 cm inferior of the clavicle along with the medioclavicular line, approximately 2 to 3 cm anterior and medial to the axillary fold. A subcutaneous working space of 3 cm 5 cm between the middle one third of the clavicle and sternoclavicular joint was made using blunt dissection with a periosteal elevator. A 5-mm trocar was inserted for a 30-degree 4-mm arthroscope, and isotonic sodium chloride solution (containing 1-mg adrenaline per 3000-mL isotonic sodium chloride solution) was then injected constantly. This reduces bleeding during the procedure and ensures that the surgical field remains clear. Next, the other incision was made at 10 cm inferior of the sternoclavicular joint for a motorized shaver and a radiofrequency device (ArthroCare Corporation; shaft size of 3.0 mm, angle of 50 degrees, and mode of cut or coagulate) (Fig. 1C). Under arthroscopic guidance, we used the motorized shaver to debride the connective tissue attachments, thereby exposing the affected SCM (Fig. 2A). The radiofrequency device was then introduced through the same portal and sectioned the distal insertion of the SCM at the surface of the sternum and clavicle (Fig. 2B). For the recognition and release of the muscle, it was beneficial when the patients lifted their head to tighten the SCM during the procedure. Good hemostasis was maintained throughout the entire surgery to allow for a clear observation of the surgery and prevent hematoma formation after the operation. This was achieved by coagulation of any bleeding point using radiofrequency energy, increasing the pressure of the saline inflow, and supplementing the saline solution with adrenaline. Care was taken to assess for additional restricting bands and active bleeding. There was no need for a neck collar for the patients after the operation. The patients were educated on appropriate stretching
FIGURE 2. Arthroscopic view during the procedure. A, Exposing the affected SCM. B, Sectioning the affected SCM using the radiofrequency device.
Excellent
Good
Fair
Poor
(3 Points)
(2 Points)
(1 Point)
(0 Points)
6–10 6–10 Mild
11–15 11–15 Moderate
>15 >15 Severe
Rotational deficit, degrees ≤5 Lateral flexion deficit, degrees ≤5 Craniofacial asymmetry No (no, mild, moderate, severe) Scar (no, mild, moderate, severe) No Residual contracture No (no, lateral, clavicular, sternal) Head tilt (no, mild, No moderate, severe) Subjective assessment Excellent (cosmetic and functional) Overall scores 17–21
Mild Lateral Mild
Moderate Severe Lateral, Clavicular, clavicular sternal Moderate Severe
Good
Fair
Poor
12–16
7–11
