Telephone , fax , e-mail moc. All rights reserved This article has been cited by other articles in PMC. Abstract Forequarter interscapulothoracic amputation is a major ablative surgical procedure that was originally described to manage traumatic injuries of the upper extremity. Currently, it is most commonly used in the treatment of malignant tumours of the arm. With the advent of limb-sparing techniques, primary forequarter amputation is performed less frequently, but remains a powerful surgical option in managing malignant tumours of the upper extremity; therefore, surgeons should be familiar with this procedure. A classic case report of forequarter amputation, with emphasis on indications and surgical techniques, is presented.
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Raphael E. Because of the lack of hemostatic techniques and antibiotic therapy, amputation was previously associated with a high mortality rate. The earliest report on the use of surgical forequarter amputation, or interscapulothoracic amputation, was published by Cuming in 1.
Unfortunately, the patient died of gangrene a few days following the procedure. Because of the advances in regional and systemic therapies, radical amputation procedures are rarely performed. Forequarter amputation is performed almost exclusively for tumors of the shoulder girdle or surrounding soft tissues that invade the glenohumeral joint, the brachial plexus, or the axillary vasculature, making limb salvage or shoulder disarticulation unfeasible.
This radical operation has been selectively utilized in the treatment of recurrent breast cancer, specifically when there is disease in the axilla 2. Recurrent tumor in the axilla with invasion into the brachial plexus and axillary vessels can lead to significant morbidity secondary to pain, lymphedema, limb dysfunction, and ulceration.
A core needle biopsy or incisional biopsy is recommended to confirm the diagnosis prior to any surgical intervention 4. The placement of the biopsy site should be chosen carefully, as it will need to be included in the formal resection. High-quality, contrast-enhanced computed tomography CT scanning can define all necessary anatomical details that will be important in determining resectability 5 , 6. Magnetic resonance imaging MRI has the advantage of providing a more detailed assessment of individual muscle involvement and extent of brachial plexus involvement in selected patients 6.
In equivocal cases a local exploration with intra-operative biopsies may be needed Fig. Figure The nutritional status and immunocompetence of the patient should be assessed prior to operative intervention. Malnourished or immunocompromised patients will have markedly increased rates of perioperative complications that may prevent a successful recovery. The forequarter amputation is a radical procedure that will result in a hypermetabolic state postoperatively.
Significant medical comorbidities or any active infection should be addressed prior to surgery. Depending on the extent of the tumor, this procedure can involve significant blood loss and plans for perioperative transfusion should be made. From Pollock RE. The need for additional skin and soft-tissue coverage of the amputation site should be considered preoperatively. When the tumor involves a considerable portion of the medial aspect of the axillary skin and soft tissue, the resection defect following forequarter amputation will often necessitate the use of split thickness skin grafts or myocutaneous flaps for wound closure.
A fasciocutaneous deltoid flap can be utilized when a proximal but medial tumor necessitates more skin and soft-tissue resection near the chest wall. If the resection necessitates removal of more than two ribs, coverage of the defect and stabilization of the chest wall will be needed and consultation with a plastic and reconstructive surgeon should be obtained.
Surgery Forequarter amputation removes the entire upper extremity in the interval between the scapula and the chest wall 7 , 8 , 9. Resection of the chest wall may also be required Fig. Three approaches to the forequarter amputation have been described: Anterior approach Berger Combination of the anterior and posterior approaches Positioning The patient should be placed in a lateral decubitus position with the affected side up and secured to the operating table at several points.
The affected shoulder, axillary region, and upper extremity should be prepped with sterile solution and draped with a wide operative field.
The upper extremity should be prepped free and covered with a stocking so that it can be manipulated to facilitate exposure during the procedure. Operative Technique for the Posterior Approach The posterior approach to the forequarter amputation requires two incisions: one posterior cervicoscapular and one anterior pectoroaxillary Fig. If a fasciocutaneous deltoid flap is required for closure of the wound, the incision will extend out over the shoulder following the outline of the deltoid muscle just distal to its insertion on the humerus Fig.
Redrawn from Cleveland KB. Amputations of the upper extremity. New York NY: Mosby, —, with permission. The posterior incision is initiated at the medial end of the clavicle and extended laterally for the entire length of the bone. The incision is then extended to the acromion and the lateral border of the scapula to the inferior angle of the scapula. Only gold members can continue reading. Log In or Register to continue You may also need.
Surgical technique[ edit ] The rhomboid muscles, trapezius, levator scapulae and latissimus dorsi are transected. The neurovascular bundle consisting of the axillary artery , axillary vein and brachial plexus is ligated and cut. The area of the chest left exposed is then normally covered with a split-thickness skin graft. He was left with a gangrenous stump and had a few days to live. A further amputation had left him open to infection, and now he was facing the prospect of an awful, agonising death over a period of several days — hallucinations, dehydration, his kidneys packing up, his breathing going and then, finally, his heart.