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Forequarter Amputation CONSTANTINE P. KARAKOUSIS, M.D., PH.D., F.A.C.S. NARRATOR: JOHN L. BUTSCH, M.D., F.A.C.S. 1 Forequarter Amputation Forequarter or Interscapulothoracic amputation involves the removal of the upper extremity including the scapula and most of the clavicle. It is performed for tumors infiltrating extensively the brachial plexus and axillary vessels. 2 Forequarter Amputation Indications 1) Forequarter amputation is indicated for patients with involvement of the brachial plexus and no distant metastases after failure to or inability to apply conservative management. 2) For patients with metastatic disease when the severity of the symptoms in the involved arm and indolent progression of the tumor make reasonable a palliative application of this procedure after failure of conservative measures. Contraindications When the plane of amputation can not be carried out through grossly clean planes. 3 Forequarter amputation ANTERIOR APPROACH: The subclavian vein is divided first, then the artery, then the trunks of plexus. POSTERIOR APPROACH: The trunks of brachial plexus are divided first, then the artery, then the vein. DELTOID FASCIOCUTANEOUS FLAP: When a defect in closure is expected. 4 Figure 1 The patient is placed in a lateral position with the affected arm free-draped. The anterior portion of the incision extends from the medial end of the clavicle to the middle of this bone. It then bifurcates, anteriorly parallel and medial to the deltopectoral groove to the axilla, and posteriorly over the lower neck toward the lateral portion of the scapula. The medial extension of the incision along the axis of the clavicle may not be necessary if one does not remove the middle third of the clavicle. The portion of the incision over the pectoralis major and axilla is made closer to the specimen to be, if the tumor location allows it, than the planned division of the muscle so that the anterior flap has a fasciocutaneous component before the pectoralis major is divided in a more medial position away from the neurovascular bundle which is involved by tumor. This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. 5 Figure 2 The posterior portion of the incision is made vertically over the middle of the scapula to its lateral border, turning in the axilla where it meets its opposite. Note that the skin incision is made more lateral than the division of the muscles (medial to the vertebral border of the scapula) preserving thus extra viable skin (fasciocutaneous portion of the posterior flap). This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. 6 Figure 3 ANTERIOR APPROACH (Berger)1,2 The medial portion of the clavicle is exposed after the attachments of pectoralis major and sternocleidomastoid are divided close to this bone. This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. 7 A right-angle clamp is passed around the clavicle near the sternal end and with a Gigli Saw the bone is divided. The same is repeated a few centimeters laterally and the segment of the bone is detached from the subclavius muscle and removed. The subclavius muscle extends from the anterior end of the first rib to the undersurface of the clavicle laterally covering the subclavian vessels . A segment of the clavicle and a smaller section of subclavius are removed to allow exposure and space for dissection around the vessels when an anterior approach is used. Figure 4 This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. 8 Figure 5 This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. A right angle clamp is passed around the subclavian vein which is ligated, suture-ligated and divided. The upper trunk of the brachial plexus is visible. 9 Figure 6 The omohyoid muscle is divided. The subclavian artery is divided between vascular clamps and the two ends are sutured with vascular sutures and a proximal tie (not visible). The brachial plexus trunks are ligated with absorbable sutures and divided. The phrenic nerve and scalenus anterior are preserved, as the internal jugular vein is retracted medially (not shown). This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. 10 Figure 7 This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. A flap from the posterior incision is made to the medial border of the scapula. The trapezius muscle is divided exposing the levator scapulae, rhomboid minor and major which are serially divided. In the inferior part of the incision the latissimus dorsi is divided. 11 Figure 8 The dissection continues between the serratus anterior and the chest wall dividing the serratus close to its origin anteriorly (2nd-9th ribs), completing the amputation. This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. 12 POSTERIOR APPROACH TO FOREQUARTER AMPUTATION •In the original procedure (Littlewood)1,2 through a posterior incision, after the muscles attaching the scapula to the spine and the omohyoid are divided the trunks of the brachial plexus, the subclavian artery, and the vein are serially divided while the skin anteriorly, the clavicle and pectoral muscles are still intact and are divided later. •In the modified procedure described below3 elements of both anterior and posterior approach are combined: •The same skin incision is used as for the anterior approach. The muscles around the scapula posteriorly are divided; these are the trapezius, levator scapulae, rhomboid minor and major. Superiorly the omohyoid muscle is divided, inferiorly the latissimus dorsi. •The pectoral muscles and clavicle are divided anteriorly. •Through a posterior approach: •The trunks of the brachial plexus are serially divided. •The subclavian artery first and then the vein are ligated and divided near the thoracic inlet, lateral to the thyrocervical trunk, i.e. lateral to scalenus anterior. 13 POSSIBLE ADVANTAGES OF THE COMBINED POSTERIOR APPROACH • In patients with prior radiation and the attendant loss of tissue planes as one dissects around the subclavian vein and artery through an anterior approach any bleeding may be difficult to control as the anatomical structures are tightly packed together. • In the combined posterior approach, with all the other tissues divided: • Control of the neurovascular bundle can be expeditious. •The trunks of the brachial plexus are divided first, then the subclavian artery and then the vein. One avoids the loss of blood in the vasculature of the specimen occurring when the vein is interrupted first. •There is a 3cm gain in proximal margin (vessels divided lateral to scalenus anterior as compared to the first rib.) •Care should be exercised in a posterior approach after all the tissues around the subclavian vessels have been divided and for the few minutes until the subclavian vessels have been controlled that the extremity be manipulated gently and supported to avoid undue traction on the vessels. 14 Closure of the incision The two sides of the incision are lined-up and any excess skin is trimmed. The edges are approximated with absorbable sutures for the fascial layer. The skin-subcutaneous fat-fascia layer of each flap extends to the edge of the incision, while the muscle layers divided more widely can not be approximated. The pectoral muscles, serratus anterior and latissimus dorsi constituting the anterior, medial and lateral walls of the axilla are in contact with the neurovascular bundle (and any tumor in this area) and can not be preserved except for their part away from the axillary space. The trapezius muscle although broad-based extends laterally only as a narrow strip inserting to the acromion. If there is not enough skin to close completely the incision, a skin graft can be applied on the chest wall in the remaining defect. When there is a concomitant gap in the chest wall exposing the pleural cavity, seal can be provided through adjacent fasciocutaneous rotation flaps, covering the area(s) from which they were moved with skin grafts; or a free flap can be transferred with microvascular surgery for its blood supply. Since tumors involving the brachial plexus are located medial to the shoulder joint, the skin-subcutaneous fat over the deltoid is usually tumor-free and can be incorporated as the deltoid fasciocutaneous flap 4 with both anterior and posterior approaches. 15 Figure 9 Deltoid Fasciocutaneous Flap The forequarter incision is made to circumscribe the outline of deltoid muscle. This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. 16 Figure 10 This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. Posteriorly it continues along the lateral border of the scapula toward the axilla. 17 Figure 11 This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission. The fasciocutaneous flap deepens as it encounters the insertion of trapezius and that of the muscles at the medial border of the scapula, so that these muscles are part of the base of the flap. Otherwise the operation proceeds as described without the deltoid flap. 18 Deltoid flaps based at the lower neck-upper back 19 The removed specimen with exposed deltoid muscle 20 En bloc rib resection showing the chest wall defect and collapsed left lung 21 Chest defect covered with a deltoid flap based on the muscles medial to the vertebral border of the scapula. The indentation in the flap corresponds to the chest wall defect. 22 Postoperative Course and Management Pain management is the main issue. Phantom pain gradually recedes with time. It is more severe and protracted in cases of neuroma development. These can be treated with conservative measures as well as through excision. It is believed that the incidence of neuromas decreases if the nerve is divided sharply under traction and allowed to retract in an adjacent muscle. Emotional support for the advantages of the procedure should be available5. Physical therapy, rehabilitation and occupational therapy are needed to strengthen the remaining arm and to teach the patient techniques to carry out tasks normally requiring both arms. Consultation regarding prosthetic devices (e.g. shoulder pad cosmetically restoring the height and roundness of the shoulder) should be offered. 23 Conclusions Both anterior and posterior approaches are equally valid and tested procedures the choice depending on the surgeon’s experience and the operative findings. The deltoid fasciocutaneous flap is usually free of tumor and can provide coverage and seal of the thoracic cavity when needed after a forequarter amputation. 24 References 1. Sim FH, Pritchard DJ, Ivins JC: Forequarter amputation. Orthop Clin North Am 8:921-931, 1977. 2. Tooms RE: Amputations of Upper Extremity. In Canale ST (ed). Campbell’s Operative Orthopaedics, Ed 9. St Louis, Mosby 550-560, 1998. 3. Ferrario T, Palmer P, Karakousis CP: Technique of forequarter (interscapulo-thoracic) amputation. Clinical Orthopedics & Related Research 423:191-195, 2004. 4. Volpe CM, Peterson S, Doerr RT, Karakousis CP: Forequarter amputation with fasciocutaneous deltoid flap reconstruction for malignant tumors of the upper extremity. Ann Surg Oncol 4: 298302, 1997. 5. Ducic I, Mesbahi AN, Attinger CE, Graw K: The Role of Peripheral Nerve Surgery in the Treatment of Chronic Pain Associated with Amputation Stumps. Hand/Peripheral Nerve, Vol 121 (3): 908-914, 2008. 25