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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