Download Radiograph showing erosion of the outer part of the spine of the

RESECTION
OF
FOR
THE
SARCOMA
This
scapula
paper
the
Orthopaedic
describes
by means
the
of block
BURWELL,
and
Accident
treatment
resection
of forty-two
increasing
and
disturb
did
not
shoulder
spine
of
THE
DEWSBURY,
Service,
the
of a patient
of the
shoulder
CASE
A man
of pain and
HUMERAL
INVOLVING
H. NEVILE
Froni
WITH
SHOULDER
SUSPENSION
SCAPULA
ENGLAND
Dewsburv
Group
with
a large
leaving
the
of Hospitals
sarcoma
rest
arising
of the
limb
his sleep,
nor
was
illness.
palpation
On
the
REPORT
employed
as a builder’s
labourer
was seen in May 1957.
stiffness
in the right shoulder
for three months.
The pain
and no previous
the scapula,
and
from
intact.
it aggravated
inspection
confirmed
by use.
There
had
been
of the shoulder
there was
an ill-defined
firm swelling,
no injury
the supraspinous
deep
to
extending
shoulder
the trapezius
and deltoid
beneath
the acromion
movements
were restricted,
tion being
a passive
although
present
through
only
range
of 80 degrees
it caused
pain.
Radiographs
and
the
and
of
of the outer
inner
the
part
of the
infraspinous
fossae
muscles
process.
active
and
The
eleva-
30 degrees
although
could
be obtained
right
halfofthe
to the
a fullness
near the
which
was tender,
involving
erosion
He complained
was not severe
shoulder
spine
acromion
showed
ofthe
scapula
(Fig.
1).
The
haemoglobin
was 104 per cent; the white cell count
was normal
; and the sedimentation
rate (Wintrobe)
was 33 millimetres
after one hour.
The
patient
was
admitted
to the General
Hospital
at Batley
and a biopsy
was taken
in June.
FIG.
I
Radiograph
showing
erosion
of the outer
part of the spine of the scapula and the inner
part of the acromion.
Histological
tumour
examination-The
having
large
“open”
nuclei
(Fig. 2). Mitotic
figures
were
high
power
field.
In some
areas
ovoid
nuclei
and the cytoplasm
There
were areas
in which
the
was that of a poorly
differentiated
felt
exploration
view
to subsequent
was
acromion.
composed
300
firm
and
the
restricted
resection.
greyish-white
extending
main
with
There
a
was
tumour
beneath
fixed
the
packed
cells
of closely
tumour
was
less
cellular,
the
cells
had
more
condensed
drawn
out suggesting
fibroblastic
differentiation
tumour
was orientated
in interlacing
bundles.
The
sarcoma,
most probably
a fibrosarcoma.
Since there
was no evidence
of metastases
that
this could
probably
be achieved
by
spinous
in
purposely
radical
nucleoli
and a poorly
demarcated
cytoplasm
in some areas
two or three
were present
in each
patient
was warned
that a forequarter
amputation
Operation-Hypotensive
anaesthesia
was used,
millimetres
until the resection
had been completed.
The posterior
incisions
were made
so as to avoid
the
was
a multilobular
to
the
scapula
with
prominent
plentiful
and
the
The
it was
resection
decided
to remove
of the shoulder
(Fig.
3).
specimen
the tumour;
it was
girdle
although
the
might
be necessary.
the systolic
pressure
being
reduced
The incisions
are shown
in Figures
the biopsy
incision
below
the lateral
to 100
4 and 5.
half of
process.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
RESECTION
OF SHOULDER
With
the
outer
limits
WITH
the
patient
supine
side
of the
shoulder
of the
incision
HUMERAL
an
incision
three
was
then
SUSPENSION
was
inches
divided
first
below
FOR
SARCOMA
made
from
INVOLVING
the
the acromion.
exposing
the
coracoid
THE
inner
end
The
deltoid
process
and
301
SCAPULA
of the
clavicle
muscle
within
the
muscles
to
the
arising
from
it which
were divided,
and turned
downwards.
The axillary
sheath
was then opened
over the third part of the axillary
artery.
In this manner
the anterior
humeral
circumflex
and
subscapular
vessels
were defined
and divided
after ligation.
The first part of the second
skin incision
was then made,
beginning
at the mid-point
of
the previous
one and curving
backwards
towards
the inner
border
of the scapula.
The inner
flap
of this
a part
of
incision
it was
was
raised
divided.
and
The
the
omo-hyoid
outer
head
of the
muscle
was
then
sternomastoid
seen
muscle
but
the
was
transverse
seen;
cervical
#{149}#{149}
.*
WI’.
*_.j_%’..
r
3
FIG.
Photomicrographs
FIG.
Figure
and
saw
suprascapular
at the inner
above-mentioned
was then gently
The
patient
of the biopsy
(Haematoxylin
specimen.
VOL.
4
vessels
third.
were not isolated
until
the clavicle
had been divided
The brachial
plexus
was defined,
and the suprascapular
skin incision.
Figure
5-Line
NO.
2,
of posterior
skin incision.
vessels
and the omo-hyoid
muscle
were divided.
The front
separated
from the back of the axillary
sheath.
was next turned
into the mid-lateral
position,
the affected
at the inferior
47 B,
400.)
of anterior
scapula
could
then
The outer
end of
incision
and eosin,
4-Line
uppermost.
The second
incision
was then continued
border
of the scapula
and to its inferior
angle
(Fig.
rhomboid
minor,
rhomboid
major
and serratus
anterior
The
..
“.
MAY
be lifted
the first
angle
1965
the line
of the
scapula
shoulder
being
vertically
a little
lateral
to the inner
5). The trapezius,
levator
scapulae,
muscles
were divided
using diathermy.
up along
its inner
border.
incision
was extended
to join
of the scapula,
with a Gigli
nerve;
the
of division
the
lower
end
of the
skin
being
of
just
the
second
below
the
302
axillary
H.
border
of the
bone.
The
lower
flap
N.
BURWELL
of skin
was
then
raised
and
the
rest
of the
deltoid
muscle
within
the limits
of the incision
and lateral
to the scapular
border,
was exposed
and
divided
by diathermy.
The long
head
of the triceps
was seen and divided.
The humerus
was divided
below
the level of the surgical
neck using a Gigli saw, and the long head of the
also divided.
The remaining
structure
was the teres
major
muscle
which
was
by diathermy
in the line of, but away from,
the lateral
border
of the scapula.
The specimen
was then removed
and, after the blood
pressure
had been restored
to normal
from
its artificial
level, the remaining
bleeding
points
were ligated.
A hole was then drilled
biceps
was
divided
through
the
(Ethicon)
upper
was
part
of the
threaded
shaft
to attach
of the
the bone
humerus
and
through
to the remaining
after
muscles
were then sutured
was closed.
Penicillin
and
before
closure
and a corrugated
drain
the wound.
The wound
was bandaged
of the radial
drain was
the stitches
being
following
day.
As it had been
above
the
radiotherapy,
level
removed
found
Mersilene
suture
of the trapezius
muscle.
operation.
8
The trapezius
and the deltoid
without
tension
and the skin
the pulsation
Progress-The
a stout
part
FIGs. 6 ro 8
6 and 7-Appearances
after operation.
8-Radiograph
of the shoulder
region
Figures
Figure
FiG.
this
upper
artery
removed
was inserted
into
firmly
and a sling
and the circulation
after two days
twelve
at operation
days
that
of section
of the humerus,
and he received
3,500-4,050
after
the
and
over the
sulphonamide
extent
powder
the deeper
part
applied.
At the
in the hand
the wound
operation.
lower
whole
The
border
it was considered
r at 200 kilovolts
THE
of the wound
was insuffiated
of the lower
half of
end of the operation
were normal.
healed
without
patient
any
returned
of the tumour
was
sepsis,
home
only
1
the
inches
advisable
to
over twenty-one
give a course
days.
JOURNAL
AND
OF
BONE
JOINT
SURGERY
of
RESECTION
OF SHOULDER
WITH
HUMERAL
SUSPENSION
FOR
SARCOMA
INVOLVING
THE
303
SCAPULA
Progress
continued
to be satisfactory
and the sling was finally
discarded
three
months
after
the operation.
At this time there
was no pain
or discomfort
and although
he was
unable
to elevate
his upper
arm, he could
place
his hand
behind
his back.
The strength
of
his hand
and
of his elbow
movements
was unimpaired.
The
clinical
and
radiographic
appearances
of the shoulder
region
after the operation
are shown
in Figures
6 to 8.
It was not possible
for him to return
referred
to an industrial
rehabilitation
was
unskilled
work
quantitative
to manage
When
and
found
employment
assessments
of small
this work
without
any
last seen nearly
seven
recurrence
limb was
of the
unchanged.
to his previous
unit.
He
tumour.
He
as
work as a builder’s
was recommended
a laboratory
assistant
making
samples
of contractor’s
sand and
difficulty
ever since.
years
after
the operation
there
had
no
pain
or
discomfort
and
labourer
and he
for simple
light
gravel
was
the
qualitative
and
has
able
; he
no
been
evidence
of
functional
state
undertaken
by
any
of the
COMMENT
Although
1828
excision
(Keevil
1949)
description
ofthe
of a block
resection
amputation
for patients
sufficient
In order
of the
and
technique
of the
have
for
been
by Ryerson
shoulder
tumour
many
was
probably
reported
(1939),
there
as described
first
instances
since
that
time,
is, so far as the writer
above,
which
was
is aware,
essential
Luke
in
including
a
no report
if forequarter
was to be avoided.
The operation
is not difficult
and would
appear
to be suitable
with malignant
tumours
involving
the scapula
where
excision
of the bone
is not
to remove
the tumour,
and where
forequarter
amputation
is usually
undertaken.
to preserve
the limb it is essential
that the main
vessels
and the brachial
plexus
are
not involved,
but this
are normally
detached
resection
is reasonably
of the
there
scapula
upper
arm,
can
be determined
at an early stage of the operation
when these structures
from
the scapula
without
difficulty.
The cosmetic
result
of shoulder
good and although
it is only possible
to retain
some rotary
movement
the humerus
is
stable
and
the function
of the elbow
and
hand
is not
impaired.
which
was
SUMMARY
1. Resection
extensive
for
2.
The
I would
of the
treatment
procedure
shoulder
for
by excision
is suggested
like to thank
a malignant
of the bone
tumour
involving
is described.
as an alternative
Dr C. G. Woods
of Leeds
to forequarter
for the histological
the
scapula
amputation
report
and
in suitable
too
instances.
for the photomicrographs
REFERENCES
J. J. (1949):
KEEVIL,
Surgery,
RYERSON,
31-B,
E. W. (1939):
A,nerican
VOL.
Ralph
47 B, NO.
Medical
2,
Cuming
and
Interscapulo-thoracic
Amputation
in 1808.
Journal
ofBone
and
Joint
589.
MAY
Excision
Association,
1965
of Scapula:
113, 1958.
Report
of Case with Excellent
Functional
Result.
Journal
of the