Dystrophic and nondystrophic causes of scapular winging can result in pain, severe shoulder disability, and an unacceptable appearance. Patients refractory to nonsurgical management are candidates for surgical intervention. Although tendon transfers have been described as a surgical option to gain better scapular positioning and enable better control of the scapula, they do not always result in reliable pain relief and scapular stability. An alternative to tendon transfer is scapulothoracic fusion. This salvage procedure is used to alleviate chronic pain and disability. Scapulothoracic fusion is a technically demanding procedure that requires a thorough understanding of the periscapular anatomy as well as attention to steps that promote successful fusion between the scapula and the underlying ribs. The goal of scapulothoracic fusion is to create a solid union between the anterior surface of the scapula and the posterior thorax, primarily to alleviate discomfort and provide improved function. If solid fusion is achieved, winging is eliminated and, as a result, a more agreeable cosmetic appearance is achieved. Meticulous technique performed by an experienced orthopaedic surgeon, in addition to appropriate postoperative care and rehabilitation, is required to optimize results.