What is the modified Woodward procedure technique?

September 22, 2025 •

5 min read

Sprengel deformity, the most common congenital anomaly of the shoulder, affects the scapula's position and mobility. To correct this condition, surgeons often rely on a specialized orthopedic surgery called the modified Woodward procedure technique, which aims to lower the elevated scapula and improve shoulder function.

Quick Summary

The modified Woodward procedure is a surgical technique for treating Sprengel deformity, involving muscle relocation and resection of the scapula's prominent superomedial border to lower the shoulder blade and improve range of motion and cosmetic appearance.

Key Points

Refined Surgical Approach: The modified Woodward procedure is an advanced surgical technique for treating congenital Sprengel deformity.
Corrects Scapular Position: It works by lowering the elevated and medially rotated scapula into a more normal, anatomical position.
Enhances Cosmetic and Functional Outcomes: Key modifications, including bone resection and muscle repositioning, lead to better cosmetic results and improved shoulder abduction.
Reduces Risk of Nerve Injury: The addition of bone resection and optional clavicle osteotomy minimizes the risk of damage to the brachial plexus nerves during surgery.
Addresses the Underlying Cause: The procedure targets the muscular and bony abnormalities responsible for the deformity, providing a comprehensive correction.
Involves a Recovery Phase: Post-operative care includes immobilization and physical therapy to ensure a successful recovery and restored function.

Understanding Sprengel Deformity

Sprengel deformity is a congenital condition characterized by an undescended and often hypoplastic scapula (shoulder blade), resulting in a visibly elevated and medially rotated shoulder. This condition is caused by an interruption of the scapula's normal caudal migration during fetal development. It can manifest in varying degrees of severity, from a mild, barely noticeable asymmetry to a severe deformity with significant functional and cosmetic limitations. The severity is often classified using the Cavendish system, which ranges from a mild Grade 1 to a severe Grade 4, with surgery typically reserved for moderate to severe cases. Patients with Sprengel deformity may also have an omovertebral bar, an abnormal bony or fibrous connection between the scapula and the cervical spine that further restricts movement.

The Original Woodward Procedure

The original Woodward procedure was developed to correct Sprengel deformity by addressing the muscle imbalances contributing to the elevated scapula. Described in 1961, the technique involves detaching the origins of the trapezius and rhomboid muscles from the spinous processes of the vertebrae. Surgeons would then move these muscles downward, reattaching them at a lower position on the spine to effectively pull the scapula into a more anatomical, lowered position. Any omovertebral bar or fibrotic tissue found was also excised. While effective, this original approach sometimes posed a higher risk of complications, including brachial plexus injury, particularly in older patients or severe deformities.

What is the Modified Woodward Procedure Technique?

The modified Woodward procedure builds upon the original technique by incorporating key refinements to improve outcomes and minimize risks. A notable modification, often attributed to Borges and colleagues in 1996, added the resection (excision) of the prominent superomedial border of the scapula. This bone resection is performed after the muscles are detached and allows for a more complete release, enabling the scapula to be lowered more effectively and improving the overall cosmetic appearance. In some cases, particularly in older patients or severe deformities, a clavicle osteotomy (cutting the clavicle) may also be performed as part of the modified procedure. This extra step provides additional surgical release, helping to prevent tension on the brachial plexus nerves and further enhancing the correction.

The Step-by-Step Surgical Process

The modified Woodward procedure is performed under general anesthesia and follows a precise sequence of steps to achieve optimal results:

Patient Positioning and Incision: The patient is typically placed in a prone position. A midline longitudinal incision is made over the affected shoulder region, extending from the cervical to the thoracic vertebrae to provide adequate surgical exposure.
Muscle Detachment and Visualization: The surgeon carefully dissects and detaches the origins of the trapezius and rhomboid muscles from the spinous processes of the vertebrae. This exposes the elevated scapula and any underlying structures.
Release of Fibrous and Bony Tethers: Any fibrous bands or omovertebral bone connecting the superomedial angle of the scapula to the cervical spine are identified and excised to free the scapula.
Resection of the Scapula: The prominent superomedial border of the scapula is carefully resected using a bone cutter or similar instrument. This bony excision is a critical part of the modified technique that facilitates greater downward mobilization and improves cosmetics.
Clavicle Osteotomy (If Necessary): In selected cases, a subperiosteal resection of the middle segment of the clavicle may be performed to allow for further descent of the scapula and reduce pressure on the brachial plexus.
Scapular Relocation and Fixation: The scapula is then gently moved caudally (downward) and rotated into a more anatomical position, often verified by comparing it to the opposite shoulder. It is temporarily stabilized in its new position.
Muscle Reattachment and Closure: The trapezius and rhomboid muscles are reattached to the spinous processes at a lower level, anchoring the scapula in its corrected position. The incision is then closed in layers.

Comparing the Original and Modified Woodward Procedures


Feature	Original Woodward Procedure	Modified Woodward Procedure
Surgical Action	Detaches and repositions muscle origins on the spine.	Detaches and repositions muscle origins AND resects the prominent superomedial border of the scapula.
Scapular Fixation	Anchoring sutures are used to stabilize the repositioned muscles and scapula.	Scapula is anchored with sutures after bone resection and muscle reattachment.
Cosmetic Improvement	Relies on muscle repositioning to lower the scapula and improve appearance.	Significant improvement in appearance due to both muscle repositioning and bone resection.
Functional Outcome	Aims to improve shoulder abduction by releasing muscle tension.	Aims to improve shoulder abduction with greater release and less risk of neurovascular issues.
Brachial Plexus Risk	Potential risk, especially in older patients or severe cases.	Reduced risk due to the added release from bone resection and optional clavicle osteotomy.

Recovery and Rehabilitation

Post-surgery, the patient will typically have their arm immobilized in a sling for a period to protect the surgical site. Pain management is crucial in the immediate recovery phase. A structured rehabilitation program is essential for restoring range of motion, strength, and function to the shoulder. Physical therapy exercises focus on gradual, controlled movements to prevent stiffness and ensure the best possible outcome. Full recovery can take several months, and long-term follow-up is necessary to monitor the patient's progress, especially in children as they grow.

Potential Risks and Complications

While the modified Woodward procedure is a reliable and effective technique, potential risks and complications must be considered. These can include:

Brachial Plexus Injury: Though reduced in the modified technique, nerve damage to the brachial plexus is the most severe potential complication, potentially leading to arm weakness or paralysis.
Hypertrophic Scarring: The surgical incision can sometimes result in a thick, raised scar, which is a cosmetic concern for some patients.
Recurrence of Deformity: In some cases, the elevated position of the scapula can recur, particularly with skeletal growth in younger children.
Winged Scapula: The shoulder blade may protrude outwards from the back, causing functional and cosmetic issues.
Wound Healing Issues: Infection or delayed healing of the surgical incision can occur.

Conclusion

The modified Woodward procedure technique offers a significantly improved approach to treating Sprengel deformity compared to the original method. By incorporating the resection of the superomedial scapular border and, when necessary, clavicle osteotomy, it provides superior cosmetic correction and functional improvement with a reduced risk of serious complications like brachial plexus injury. For patients, particularly young children with moderate to severe cases, this procedure can make a profound difference in both physical appearance and quality of life. Consultations with an experienced pediatric orthopedic surgeon and a thorough understanding of the procedure and its associated recovery are essential for achieving the best possible results. You can find more information about the procedure and its outcomes in studies found on sources like National Institutes of Health (NIH).

Frequently Asked Questions

Sprengel deformity is a congenital condition where the scapula (shoulder blade) is elevated and rotated inward. The modified Woodward procedure is used to surgically lower the scapula, improve shoulder function, and enhance the cosmetic appearance, particularly in moderate to severe cases.

The main difference is the addition of resecting (cutting away) the prominent superomedial border of the scapula. This modification, along with the optional clavicle osteotomy, provides a more complete release, allowing for greater scapular descent and reducing the risk of brachial plexus injury.

Yes, the procedure is commonly performed in young children, as surgery at a younger age is associated with better functional outcomes. Age is a factor considered in the treatment plan, and intraoperative neuromonitoring is often used to ensure nerve safety.

After surgery, the arm is typically immobilized in a sling for a period. A physical therapy program is then initiated to regain range of motion, and regular follow-ups are scheduled to monitor the child's growth and the correction over time.

While the modified technique is safer than the original, risks can include brachial plexus injury (nerve damage), hypertrophic scarring, and, rarely, recurrence of the deformity. Careful surgical technique and monitoring minimize these risks.

The duration of the surgery can vary depending on the severity of the deformity and whether additional procedures, like a clavicle osteotomy, are needed. The surgical team will provide a more specific time estimate based on the patient's case.

Yes, studies on the long-term results of the modified Woodward procedure have shown that the cosmetic improvement is often well-maintained beyond skeletal maturity, even with a period of rapid growth during childhood.