misr

1. MISR

2. BASIC ANATOMY
 Scapula from 2 to 7 rib
 Superior angle is covered by trapezius
 Inferior angle is covered by lattismus dorsi
 Lateral angle – capsule of shoulder joint
 Costal surface – subscapularis
 Supraspinatus fossa supraspinatus
 Infraspinatus fossa infraspinatus muscle
 Upper 2/3rd of lat border teres minor
 Lower 1/3rd teres major

3.  Medial border – serratus ant
 Superior angle to root of spine – levator scapulae
 Rhomboidus minor – root of spine
 Between root of spine and inferior angle –
rhomboidus major
 Supraglenoid tubercle – long head of biceps
 Infraglenoid tubercle – long head of triceps
 Upper lip of spine of scapula trapezius
 Lower lip - deltoid

4. 2 year old boy
Restricted shoulder abd and ER
Passive ext rotation-20*
Axial MRI shows pseudoglenoid formn with
post subluxation of humeral head waters
type 4

5. Post MISR and tendon transfer after 1 year,
Axial MRI shows well reduced GH joint, with
glenoid retroversion diff of 5 degrees.
Excellent remodelling of GH joint.

6. Arm is internally rotated and foorward
flexed to make the medial border of
scapula prominent.

7. A curved artery forceps is introduced
through subcutaneous tissue and
rhomboids to reach the undersurface of
scapula and widened.

8. Periosteal elevator is introduced to release
subscapularis in a clockwise manner.

9. 90 degrees passive ER achieved after MISR .
Elbow flexed at 90 degrees and gentle
stretching of anterior shoulder capsule and
ligaments done over 5 minutes, after
stabilizing the elbow joint.

10. Circumflex scapular
vessels enter the
substance of
subscapularis b/w
the bed of teres
minor and teres
major , at junction
of upper 2/5 and
lower 3/5 of lateral
border of scapula
and continues
distally as
thoracodorsal
vessels
Reflected posterior deltoid
from spine of scapula
Spine of scapula
Reflected teres major and lattismus
dorsi

11. If we consider the entry point for
MISR as center of clock , then
circumflex scapular vessels lies at
3’o clock position.

12. Suprascapular neurovascular bundle lies dorsally over the
supraspinous part of scapula.

13. If we consider the entry point for MISR
as a center of a clock it lies at 1:30
position.

14. Right scapula
Entry
point for
MISR CIRCUMFLEX
SCAPULAR
VESSELS
Suprascapular
NV bundle

15.  Open subscapularis slide from its origin
through the lateral border of scapula
 Anterior complete / z lengthening from its
insertion.
 Arthroscopic anterior release.
 These procedures were associated with ER
contracture and IR weakness.
Various methods of subscapularis
lengthening
STARTING POINT FOR LATERAL
SUBSCAPULARIS SLIDE ? IS IT BETWEEN TERES
MINOR ANDTERES MAJOR
Q

16. COSTAL ASPECT

17. DORSAL ASPECT

18. Q
If circumflexscapular vessels lay in the bed between
teres minor and teres major, then how it gives branch
to subscapularis at junction of upper 2/5 and lower
3/5 of the lateral border of scapula.

19. RIGHT SCAPULA
BE CAREFUL
BETWEEN 1 AND 3’0
CLOCK POSITION.

20. LEFT SCAPULA
BE CAREFUL BETWEEN
11 AND 9’0 CLOCK
POSITION

21. MISR is extra periosteal and
submuscular.
Serratus anterior and rhomboid
attachments would be intact except at
entry point.

22.  Lateral position
 Arm was internally rotated and forward
flexed to make the medial border more
prominent
 1 cm incision was placed at junction of upper
1/3rd and lower 2/3rd of scapula
 A blunt curved hemostat was advanced thru
rhomboids to reach the undersurface of
scapula.
Surgical technique

23.  Hemostat was widenend and withdrawn
 A 4mm curved periosteal elevator was
introduced with its concave surface facing the
body of scapula.
 In a clockwise manner , subscapularis slide
was performed.
 Subsequently , a broader (6mm) curved
periosteal elevator was introduced rest of the
thicker septae at uperomedial and inferior
angle were released.

24.  It was followed by gentle stretching of
shoulder internal rotators and anterior
capsule for 5 minutes.
 For this shoulder was stabilized with arm
adducted, elbow flexed at 90 degrees and
forearm was kept in full supination.
 The procedure lasts for about 8-10 min
 5 min for MISR , 5 min of gentle stretching of
arm.

25.  One should achieve 70-80 degrees of free ext
rotation. And the last 10-20 degrees may
remain springy.
 Procedure is followed by conjoint tendon
transfer
 Shoulder spica is applied in 45 degrees of
abd, 60 degrees of ext rotation, 90 degree of
elbow flexion for 5 weeks
 After that a customized splint is worn to keep
arm in abd and ext rot at night for3 months