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Copyright (c) 2025 Slovenian Medical Journal. This work is licensed under a
Creative Commons Attribution-NonCommercial 4.0 International License.
En-bloc resection of scapular chondrosarcoma with 
intraoperative computer navigation
En-bloc resekcija hondrosarkoma lopatice z uporabo intraoperativne računalniške 
navigacije
Igor Potparić, David Martinčič
Abstract
Background: Surgical removal of scapular tumours presents a complex problem due to the vicinity of major nerves and 
blood vessels and its functional importance. Planning such a procedure presents a significant challenge, further com-
plicated by varia-bles such as histological findings, tumour location, and size. In recent years, the development of 3-D 
imaging, modelling, and printing has proven to be helpful in planning and improving the safety and accuracy regarding 
major anatomical structures and minimalisation of healthy tissue resection. With modern modalities, we can more readily 
adhere to the recommendation of limb-salvage surgery. So far, computer-navigated surgery has been used for chondro-
sarcoma resections of long bones, pelvis, sacrum, and spine, but very few reports provide insight into scapular chondro-
sarcoma resections using computer navigation.
Case presentation: We present a case of a 36-year-old male with a secondary chondrosarcoma grade 1, where “en bloc” 
resection was successfully performed by using MR- and CT-based intraoperative computer navigation.
Discussion: Surgery remains the sole treatment for chondrosarcomas, aiming for complete tumour resection with nega-
tive margins while preserving limb function. Successful use of surgical navigation has been documented in various bones, 
yielding precise bony resection but not soft tissue margins.
Conclusion: We applied principles of chondrosarcoma treatment to scapular chondrosarcoma, achieving functional 
shoulder preservation. Combining navigation with PSI could enhance surgical outcomes, though challenges include tech-
nology availability and variability in patient cases.
Department of Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
Correspondence / Korespondenca: Igor Potparić, e: igor.potparic@gmail.com
Keywords: chondrosarcoma; shoulder joint chondrosarcoma; total en bloc resection; computer navigation surgery; limb-preserving 
surgery
Ključne besede: hondrosarkom; hondrosarkom ramenskega sklepa; totalna resekcija en bloc; računalniško vodena navigacija; 
ohranitvena kirurgija
Received / Prispelo: 16. 7. 2024 | Accepted / Sprejeto: 18. 10. 2024
Cite as / Citirajte kot: Potparić I, Martinčič D. En-bloc resection of scapular chondrosarcoma with intraoperative computer navigation. 
Zdrav Vestn. 2025;94(1–2):32–8. DOI: https://doi.org/10.6016/ZdravVestn.3560
eng slo element
en article-lang
10.6016/ZdravVestn.3560 doi
16.7.2024 date-received
18.10.2024 date-accepted
Surgery, orthopaedics, traumatology Kirurgija, ortopedija, travmatologija discipline
Case report Klinični primer article-type
En-bloc resection of scapular chondrosarcoma 
with intraoperative computer navigation
En-bloc resekcija hondrosarkoma lopatice z upo-
rabo intraoperativne računalniške navigacije article-title
En-bloc resection of scapular chondrosarcoma 
with intraoperative computer navigation
En-bloc resekcija hondrosarkoma lopatice z upo-
rabo intraoperativne računalniške navigacije alt-title
chondrosarcoma, shoulder joint chondro-
sarcoma, total en bloc resection, computer 
navigation surgery, limb-preserving surgery
hondrosarkom, hondrosarkom ramenskega skle-
pa, totalna resekcija en bloc, računalniško vodena 
navigacija, ohranitvena kirurgija
kwd-group
The authors declare that there are no conflicts 
of interest present.
Avtorji so izjavili, da ne obstajajo nobeni 
konkurenčni interesi. conflict
year volume first month last month first page last page
2025 94 1 2 32 38
name surname aff email
Igor Potparić 1 igor.potparic@gmail.com
name surname aff
David Martinčič 1
eng slo aff-id
Department of Orthopaedic 
Surgery, University Medical 
Centre Ljubljana, Ljubljana, 
Slovenia
Ortopedska klinika, Univerzitetni 
klinični center Ljubljana, 
Ljubljana, Slovenija
1
Slovenian Medical Journallovenian Medical Journal
33
CASE REPORT
En-bloc resection of scapular chondrosarcoma with intraoperative computer navigation
1 Introduction
The second most common primary malignant tu-
mour of bone requiring surgical treatment is chondro-
sarcoma (1,2), 20% of which develops in the shoulder 
girdle (2). With surgical resection being the definitive 
treatment (1-5) and the functional outcome varying 
on the surgical technique and location of the resected 
part (1,2), the outcome is more favourable if the gleno-
humeral joint can be preserved (1-3). As imaging and 
computer rendering of images evolve, surgical options 
become more abundant. With MR- and CT-based 
navigation and other navigation techniques, we might 
be able to spare certain patients from total scapulec-
tomies and unnecessary radical healthy tissue resec-
tion, which have been shown to have worse functional 
and aesthetic outcomes than joint-saving procedures 
(1-4).
Although computer navigation surgery is common 
in shoulder arthroplasty, where it has shown its prac-
ticality (5), not much has been reported on its use in 
scapular tumour surgery. So far, we have found only 
one case report by Deng et al. (6) of using 3-D imaging 
and printing to produce patient-specific partial scap-
ular prosthesis and navigation template. In this case 
report, we detail the inaugural case of scapular chon-
drosarcoma limb-preserving surgery employing in-
tra-operative MR- and CT-based navigation (Ekliptik, 
Slovenia, EU) (7). Our surgical approach aims to pre-
serve critical functional segments of the scapula, there-
by optimizing postoperative functional outcomes. By 
leveraging the precision and enhanced visualization 
Izvleček
Izhodišča: Kirurška odstranitev tumorjev lopatice je kompleksen problem zaradi bližine pomembnih živcev, žil in funkcij-
ske pomembnosti. Načrtovanje takega posega je velik izziv, ki ga dodatno otežijo spremenljivke, kot so histološke ugoto-
vitve, mesto tumorja in njegova velikost. V zadnjih letih se je razvoj 3-D slikovnih preiskav, modeliranja in tiskanja izkazal 
kot uporabna tehnologija pri načrtovanju, izboljšanju varnosti in natančnosti posegov pri pomembnih anatomskih struk-
turah in odstranitvi čim manj zdravih tkiv. S sodobnimi sredstvi lahko pogosteje in bolj natančno upoštevamo priporočila 
ohranitvene kirurgije. Doslej se je računalniško vodena kirurgija uporabljala pri resekciji hondrosarkomov dolgih kosti, 
medenice, križnice in hrbtenice, toda zelo malo je poročil o uporabi računalniške navigacije pri tumorjih lopatice. 
Predstavitev primera: Pri 36-letnem moškem s sekundarnim hondrosarkomom gradusa-1 smo uspešno opravili t. i. ‘’en 
bloc’’ resekcijo s pomočjo računalniške navigacije med operacijo, osnovane na CT in MRI.
Razprava: Kirurška oskrba je edino dokončno zdravljenje hondrosarkomov s ciljem popolno odstraniti tumor s tumorsko 
negativnimi robovi, a hkrati ob ohranitvi funkcije uda. Uspešno uporabo kirurške navigacije na različnih kosteh so že opi-
sali in poročali o natančni resekciji kostnine, ne pa nekirurške navigacije tudi brez mehkotkivnih robov.
Zaključek: Z uporabo načel zdravljenja hondrosarkomov ob uporabi računalniško vodene navigacije smo pri zdravljenju 
hondrosarkoma lopatice ohranili ra-mensko funkcijo. Združitev navigacije in PSI bi lahko izboljšala izide operacij, a izzivi, 
kot so dostopnost tehnologije in variabilnost med primeri, so še vedno prisotni.
afforded by intra-operative navigation, this technique 
aligns with contemporary surgical practices focused 
on maximizing musculoskeletal integrity and func-
tion in complex oncological resections. We decided 
to use MR- and CT-based -navigation to increase the 
accuracy of surgical resection and improve the odds of 
preserving the glenohumeral joint and other function-
ally important parts of the shoulder joint and girdle.
2 Case presentation
A healthy 36-year-old male without chronic diseas-
es was administered and examined in the orthopedic 
emergency department due to a growing mass in the 
right supraclavicular fossa. He described mild discom-
fort during hiking with hiking poles and an occasional 
tingling sensation in the right arm. Upon inspection, a 
solid, painless, and immovable resistance was palpable 
above the clavicle. The skin was not showing signs of 
inflammation or necrosis, and no neurological deficits 
were found except for occasional paresthesias in ex-
treme shoulder positions.
Ultrasonography imaging showed an 8 x 7 cm tu-
mour formation in the area of the medial clavicle cor-
tex with signs of calcification and ossification. The pa-
tient was referred for an MRI, which showed a lobular 
tumour formation 9 x 9 x 4.5 cm in size, protruding 
from the coracoid process and anteriorly touching the 
clavicle but showing no invasion into the cortex. Api-
cally, it was almost at the height of the m. trapezius, 
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Zdrav Vestn | January – February | Volume 94 | https://doi.org/10.6016/ZdravVestn.3560
distally to the third rib, with possible invasion of m. 
subscapularis. Signs of mild atrophy of m. supraspina-
tus and infraspinatus were also present and accredited 
to the n. suprascapularis entrapment.
Two consecutive core needle biopsies through the 
same incision were conducted, and both came up as 
inconclusive. Additionally, a PET-CT was conducted, 
which showed a mild metabolic increase in regions of 
tissue where calcination was ongoing but could not be 
differentiated as malignant or benign. A tumour board 
with oncology specialists was held where it was decid-
ed to perform an open incision biopsy under general 
anesthesia. An open biopsy was conducted, and a yel-
lowish multi-fragment sample of a combined volume 
of 6 x 5 x 1.5 cm was obtained. The histopathological 
analysis of open biopsy resulted in a differential di-
agnosis of either periosteal chondroma or perioste-
al chondrosarcoma grade 1. Due to slow, permanent 
tumour growth, large tumour size, and aggressive ra-
diological features, the tumour board proposed “en 
bloc” wide-margin resection of the tumour as the best 
treatment option, whereby it was estimated that the 
glenohumeral joint could be preserved.
An international expert-to-expert teleconference 
meeting was additionally organized with a reference 
sarcoma expert, Prof. Dr. Med. et Dr. Sc. Nat. Bruno 
Fuchs, Luzern, Switzerland, in order to clarify the 
indication and details of the surgical plan with func-
tion-preserving wide resection and preservation of the 
glenoid and the inferior angle of the scapula.
Planning was done by using a commercial MR- and 
CT-based navigation software for osteotomies, Guid-
ing Star – Ekliptik (7). First, a virtual 3-D model was 
rendered from MR and CT imaging with the tumour 
being marked (Figure 1).
After careful consideration and MRI imaging, a 
wide portion of the scapula above and anteriorly of the 
spina scapularis was marked for resection along with 
the coracoid process and the medial and distal part 
of the clavicle, but with the glenoid and the shoulder 
joint remaining intact. Three planes of excision were 
later marked (Figure 2). A preoperative 3D comput-
er model of the resected scapula was also made as a 
reference.
Figure 1: Virtual 3-D model rendered from MR and CT imaging with marked tumour.
Source: archive of the Department of Orthopaedic Surgery, University Medical Centre Ljubljana.
35
CASE REPORT
En-bloc resection of scapular chondrosarcoma with intraoperative computer navigation
The surgical procedure was performed in the 
beach-chair position under general anesthesia. An an-
terior/posterior approach was utilized, similar to the 
Tikhoff-Linberg resection. Scapula mobilization was 
done by m. trapezius release so that the fossa supra-
spinata with m. supraspinatus could be explored and 
thoroughly assessed. After scapular mobilization, an 
anterior approach was utilized to mobilize the vessels 
and nerves and expose the clavicle, where osteotomy 
was performed in the medial part of the diaphysis. Af-
ter the scapula and crucial soft tissue release, a special 
probe was inserted into the healthy bone of the pos-
terior part of the scapula, and an imaging calibration 
scan was done. Subsequently, an intraoperative com-
puter navigation was used to guide K-wires as refer-
ence points for the osteotomy planes and cuts in the 
scapula. During the operation, a major decision to 
keep the coracoid’s distal portion was made to keep 
the insertions of the biceps short head and m. coraco-
brachialis intact. The resected part with the insertions 
was fixated anteriorly next to the glenoid, thus pre-
serving the muscles and most of their function. The 
osteotomy gaps were not grafted, and the medial por-
tion of the clavicle was left in situ without fixation. A 
final navigation-guided assessment was done, which 
showed the desired resection with optimally placed 
cuts. After resection, an X-ray image of the resected 
tissue (Figure 3) was taken.
Following the procedure, a standard postoperative 
regimen was followed. A six-week follow-up showed 
good recovery, slight edema of soft tissues was pres-
ent without palpable tenderness, and active abduction 
and flexion of 40 degrees was achieved. A six-month 
follow-up showed great rehabilitation, active abduc-
tion of 90 degrees, flexion of 160 degrees, external ro-
tation of 50 degrees, and internal rotation with reach 
to the thoracic spine. The elbow, wrist, and finger 
joints showed no deficit in function compared to the 
healthy arm.
The histology report of the removed tumour 
Figure 2: Three planes of excision marked on the 3-D model in different views.
Source: archive of the Department of Orthopaedic Surgery, University Medical Centre Ljubljana.
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SURGERY, ORTHOPAEDICS, TRAUMATOLOGY
Zdrav Vestn | January – February | Volume 94 | https://doi.org/10.6016/ZdravVestn.3560
confirmed a successful wide resection with no pres-
ence of tumour cells in the resection margin and the 
diagnosis was periosteal chondrosarcoma grade 1. 
The postoperative Mesenchymal tumour board decid-
ed that no chemotherapy or radiotherapy was needed 
since the tumour was entirely removed “en bloc”, no 
metastasis was found prior to surgery and its grade 
and histological findings were favourable. They sug-
gested regular CT and X-ray imaging of the lungs fol-
lowing the sarcoma follow-up protocol. The patient is 
to continue his rehabilitation with regular checkups. 
Currently, no further surgical or oncological interven-
tion is required.
3 Discussion
Surgery is currently the only treatment option for 
chondrosarcomas. The presented case shows how di-
agnostics of cartilagineous tumours cannot rely on 
histopathological analysis alone, and correlation with 
image interpretation by an experienced radiologist is 
mandatory to correctly assess the tumour’s aggressive-
nesstumour (8). Achieving complete tumour resection 
with negative margins is the primary surgical goal, 
preferably by preserving limb function. So far, suc-
cessful use of surgical navigation has been document-
ed in treating chondrosarcomas of long bones, pelvis, 
sacrum, and spine (9-15), with reported benefits most-
ly being tumour-free margin resection of bony struc-
tures (9,10,12,15). However, no benefit was shown for 
achieving adequate soft tissue margin resection (9,10). 
A systematic review by Bruschi et al. (9) has shown 
that both, intraoperative surgical navigation and pa-
tient-specific instrumentation (PSI), yield comparable 
results in achieving accurate tumour margin resection 
with the major drawbacks being the length of preop-
erative planning and jig production in the case of PSI 
and surgery time in case of intraoperative navigation 
use. As the benefits of surgical navigation have been 
shown in the aforementioned regions, we decided to 
extrapolate the same principles to our case of scapu-
lar chondrosarcoma. Our reasoning stands on the fact 
that in our case, the tumour was expanding anteriorly 
in such a way and extent that with precise resection, 
we could keep most of the glenohumeral joint intact 
along with functionally important structures such as 
the coracoid process and the surrounding nerves. Al-
so, one of the strong points for using MR- and CT-
based navigation in regions such as the pelvis, sacrum, 
and spine is the regional anatomical complexity and 
the navigation benefit of better visualization of the 
bony topography, which we could use in the scapula 
resection.
By using MR- and CT-based navigation, we could 
adhere to the principles of joint and limb preserving 
surgery and, as shown in our case, keep most of the 
shoulder and upper limb function by preserving the 
glenohumeral joint and adjacent muscle insertions 
crucial for upper limb function. It is important to note 
that in cases where tumour expansion occurs in the 
dorsal and/or apical direction, the proposed approach 
would be deemed suboptimal. In such scenarios, pal-
pation and resection of the tumour would be more 
feasible, allowing for the precise maintenance of the 
required surgical margins by using regular intraop-
erative X-ray imaging. Furthermore, integrating pa-
tient-specific instrumentation (PSI) and advanced sur-
gical navigation systems could synergistically enhance 
surgical outcomes. Such a combination could facilitate 
significantly faster surgery times and mitigate intraop-
erative challenges, such as the precise placement of jigs 
and sensors, ultimately leading to superior cut accura-
cy and increased operational efficiency. Nevertheless, 
the disadvantage of PSI is the need for wide exposure 
of bone and removal of adjacent soft tissues close to 
the tumour in specific anatomical locations, such as 
presented in our case report. The benefits of partial re-
section using surgical navigation could be augmented 
by using 3-D patient-specific prosthesis of the scap-
ula similar to what was shown by Deng et al. (6) in 
their case report. One of the major drawbacks is the 
lack of worldwide availability of the technology (12). 
Research in this domain is further impeded by the 
Figure 3: Postoperative X-Ray of the resected tissue.
Source: archive of the Department of Orthopaedic Surgery, 
University Medical Centre Ljubljana.
37
CASE REPORT
En-bloc resection of scapular chondrosarcoma with intraoperative computer navigation
relatively limited patient pool, coupled with significant 
variability in tumour size, type, expansion patterns, 
and the associated risks of incomplete resection and 
its sequelae. We recognize the potential of multicenter 
studies to mitigate these challenges by expanding the 
patient pool, thereby enhancing our understanding of 
tumour surgery and refining its established principles 
through integrating contemporary technological ad-
vancements. Nonetheless, it is acknowledged that this 
approach to data collection and research is fraught 
with numerous complexities and logistical challenges.
4 Conclusion
Surgical navigation shows promise in achieving 
precise resection of chondrosarcomas, particularly 
in complex anatomical regions such as the pelvis, sa-
crum, and spine. Our case extends these benefits to 
scapular chondrosarcoma, demonstrating the poten-
tial for joint and limb function preservation. Howev-
er, the technique is less effective for soft tissue margin 
resection and presents challenges such as prolonged 
preoperative planning and surgery time. Integrating 
patient-specific instrumentation (PSI) and advanced 
navigation systems could enhance surgical accu-
racy and efficiency, though the availability of such 
technology is limited. Future multicenter studies are 
References
1. Griffin AM, Shaheen M, Bell RS, Wunder JS, Ferguson PC. Oncologic 
and functional outcome of scapular chondrosarcoma. Ann Surg Oncol. 
2008;15(8):2250-6. DOI: 10.1245/s10434-008-9975-1 PMID: 18506534
2. Nota SP, Russchen MJ, Raskin KA, Mankin HJ, Hornicek FJ, Schwab JH. 
Functional and oncological outcome after surgical resection of the 
scapula and clavicle for primary chondrosarcoma. Musculoskelet Surg. 
2017;101(1):67-73. DOI: 10.1007/s12306-016-0437-9 PMID: 27900545
3. Mayil Vahanan N, Mohanlal P, Bose JC, Gangadharan R, Karthisundar V. 
The functional and oncological results after scapulectomy for scapular 
tumours: 2-16-year results. Int Orthop. 2007;31(6):831-6. DOI: 10.1007/
s00264-006-0261-1 PMID: 17043860
4. Yu XJ, Liu QK, Wang YG, Wang SX, Lu R, Xu HR, et al. Oncologic and 
functional outcomes of different reconstruction modalities after 
resection of chondrosarcoma of the scapula: a medium- to long-
term follow-up study. BMC Musculoskelet Disord. 2022;23(1):758. DOI: 
10.1186/s12891-022-05661-7 PMID: 35941682
5. Verborgt O, Vanhees M, Heylen S, Hardy P, Declercq G, Bicknell R. 
Computer navigation and patient-specific instrumentation in shoulder 
arthroplasty. Sports Med Arthrosc Rev. 2014;22(4):e42-9. DOI: 10.1097/
JSA.0000000000000045 PMID: 25370882
6. Deng L, Zhao X, Wei C, Qu W, Yu L, Zhu S. Application of a three-dimensional 
printed segmental scapula prosthesis in the treatment of scapula tumors. 
J Int Med Res. 2019;47(11):5873-82. DOI: 10.1177/0300060519875336 
PMID: 31581871
7. Ekliptik. Advanced solutions for surgery procedure. Ljubljana: Ekliptik; 
2019 [cited 2024 Jan 12]. Available from: https://www.ekliptik.si/client.
en/index.php?table=articles&ID=1295.
8. Vojković R, Martinčič D, Mavčič B. Diagnostics and treatment of 
enchondromas. Zdrav Vestn. 2022;91(7-8):345-52. DOI: 10.6016/
ZdravVestn.3226
9. Bruschi A, Donati DM, Di Bella C. What to choose in bone tumour 
resections? Patient specific instrumentation versus surgical navigation: a 
systematic review. J Bone Oncol. 2023;42. DOI: 10.1016/j.jbo.2023.100503 
PMID: 37771750
10. Bosma SE, Cleven AH, Dijkstra PD. Can Navigation Improve the Ability 
to Achieve Tumor-free Margins in Pelvic and Sacral Primary Bone 
Sarcoma Resections? A Historically Controlled Study. Clin Orthop Relat 
Res. 2019;477(7):1548-59. DOI: 10.1097/CORR.0000000000000766 PMID: 
31107331
11. Yang Y, Li Y, Liu W, Niu X. Precise single column resection and 
reconstruction with femoral head plus total hip replacement for primary 
malignant peri-acetabulum tumors. Sci Rep. 2024;14(1):3412. DOI: 
10.1038/s41598-024-52019-1 PMID: 38341503
12. Landriel F, Albergo JI, Farfalli G, Yampolsky C, Ayerza M, Aponte-Tinao 
L, et al. Navigated multiplanar osteotomies for spinal primary bone 
tumors. Surg Neurol Int. 2022;13:58. DOI: 10.25259/SNI_1232_2021 PMID: 
35242424
essential to validate these findings, optimize surgical 
techniques, and improve patient outcomes through 
advanced imaging technology. This case could help 
guide future applications, demonstrating the potential 
for improved surgical precision and patient outcomes 
by integrating cutting-edge imaging technology.
Conflict of interest
None declared.
Informed consent of the patient
The patient gave informed consent for the publica-
tion of his case.
Funding
This research received no specific grant from fund-
ing agencies in the public, commercial, or not-for-
profit sectors.
Acknowledgments
We gratefully thank Prof. Dr. med. et Dr. sc. nat. 
Bruno Fuchs, Luzern, Switzerland, for his willingness 
to discuss the planning of this challenging case and his 
dedicated comments and invaluable advice of a refer-
ence sarcoma expert. In addition, we also thank Prof. 
Dr. Blaž Mavčič for his help with both clinical work 
and preparation of the scientific article.
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SURGERY, ORTHOPAEDICS, TRAUMATOLOGY
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13. Pairojboriboon S, Sacino A, Pennington Z, Lubelski D, Yang R, Morris CD, 
et al. Nerve Root Sparing En Bloc Resection of Sacral Chondrosarcoma: 
Technical Note and Review of the Literature. Oper Neurosurg 
(Hagerstown). 2021;21(6):497-506. DOI: 10.1093/ons/opab333 PMID: 
34791405
14. Christ AB, Hansen DG, Healey JH, Fabbri N. Computer-Assisted Surgical 
Navigation for Primary and Metastatic Bone Malignancy of the Pelvis: 
Current Evidence and Future Directions. HSS J. 2021;17(3):344-50. DOI: 
10.1177/15563316211028137 PMID: 34539276
15. Abraham JA, Kenneally B, Amer K, Geller DS. Can Navigation-assisted 
Surgery Help Achieve Negative Margins in Resection of Pelvic and Sacral 
Tumors? Clin Orthop Relat Res. 2018;476(3):499-508. DOI: 10.1007/
s11999.0000000000000064 PMID: 29529631