The Forequarter Amputation

Abstract

OVERVIEW Forequarter amputation entails surgical removal of the entire upper extremity, scapula, and clavicle. It was traditionally used for the treatment of high-grade bone sarcomas of the shoulder girdle, particularly osteosarcomas of the proximal humerus and scapula. Other indications included large and high-grade sarcomas of the axilla, brachial plexus and the suprascapular area of the shoulder. As a result of advances in limb-sparing surgery for bony and soft-tissue sarcomas, forequarter amputation is rarely performed today. Only 5‐10% of patients with primary bony sarcomas, and less than 5% of those with softtissue sarcomas of the shoulder, require a forequarter amputation. Today, forequarter amputation generally is performed only for extremely large tumors arising from the proximal humerus or scapula. These lesions are usually associated with fracture, tumor‐hemorrhage, fungation, infection, and/or axillary and brachial plexus involvement. Preoperative evaluation entails examination and imaging of the potential margins of resection, particularly the underlying chest wall, paraspinal muscles, thoracic outlet and the posterior triangle of the neck. Extension into any of these areas may make it impossible to obtain surgical margins. At surgery the patient is placed in a semilateral position. The utilitarian surgical incision (see Chapter 33) is used. A semi-lateral position is used at surgery. The axillary vessels are exposed anteriorly and ligated, and the posterior structures are then released from the large, posterior, midline-based incision. Rehabilitation is begun prior to discharge from the hospital. Prostheses are available and are generally used only for cosmesis.