Forequarter Amputation Research Articles

Buried filet of limb flaps for the reconstruction of forequarter and hindquarter amputations.

Forequarter and hindquarter amputations have traditionally been closed with local tissues, but the technique is plagued by a high rate of complication such as marginal necrosis, seroma, infection, and dehiscence. Filet of limb flaps have been used when local tissues are insufficient for closure, and despite their use in more extensive and complex wounds, outcomes seem to be better in these cases. Recognizing that filet of limb flaps not only serve to cover the wound, but also eliminate dead space, supplement at-risk and/or radiated tissue, pad underlying hard structures, and facilitate neuroma prevention with target muscle reinnervation, we have change our practice to utilize buried filet of limb flaps even when local tissues are technically "sufficient" to close the wound. The purpose of this article to organize and describe the ways in which buried filet-of-limb flaps can be used to achieve important and discrete surgical objectives in forequarter and hindquarter amputation, and to facilitate increased recognition of collaborative interdisciplinary opportunities for spare-part reconstruction. Retrospective data from the medical records of seven patients, collected between 2010 to 2023 at our single tertiary referral center, were reviewed. This included all patients for whom a buried (or partially buried) filet of limb flap was attempted for forequarter or hindquarter amputation reconstruction. Five males and two females ranging 55 to 75 years of age, met the inclusion criteria. Three cases of forequarter amputation and four cases of hindquarter amputation were included. Six flaps were successfully transferred without major flap-related complications. The mean follow-up period was eight and a half months. Even when local tissues are technically "sufficient" to close forequarter and hindquarter amputation wounds, we have found buried filet of limb flaps to be useful in several ways. These include occupying dead space, providing double-layer coverage, padding hard structures, preventing neuromas, and reconstructing sacro- and spino-pelvic continuity. Our approach emphasizes interdisciplinary collaboration and highlights the potential advantages of buried filet of limb flaps in optimizing patient outcomes for complex limb amputations.

Magnetic Resonance Imaging appearance of regenerative peripheral nerve interface

PurposeTo describe the MRI appearance of Regenerative peripheral nerve interface (RPNI) and the potential association between the MR appearance and RPNI revision. Material and methodsA retrospective assessment was undertaken of the MR appearance of RPNIs performed at our institution between 1/1/2010- 7/29/2023 with clinical correlation. Results14 patients (8 males, 6 females, age range 31-80 years, median age- 51 years) with technically adequate MRI of RPNIs were included in this study including 5 patients with below knee amputation (BKA) with 5 tibial and 4 CPN RPNI, 8 patients with above knee amputations (AKA) with sciatic RPNIs and one patient following forequarter amputation with a brachial plexus RPNI. Two patients had undergone revision RPNI surgery x3 (AKA-sciatic nerve) for a total of 6 RPNI revisions. On T1 weighted sequences, all RPNIs were isointense to muscle and blended with the surrounding scar and muscle tissues while on T2 weighted sequences, all RPNIs were hyperintense in signal compared to muscle. All but one RPNI underwent post contrast enhancement in variable patterns. No statistically significant difference in MR appearance was found between RPNIs with or without a following RPNI revision surgery. ConclusionRPNI on MRI typically have a bright and intermediate signal on T2 and T1 weighted sequences accordingly, and typically undergo postcontrast enhancement in variable patterns without a statistically significant difference between cases with and without a following RPNI revision. Enhancement of RPNI should not be misconstrued as pathological.

Functional and oncological outcomes of patients with proximal humerus osteosarcoma managed by limb salvage.

Osteosarcoma is the most common primary bone malignancy in skeletally immature patients. The proximal humerus is the third most common site of osteosarcoma. The literature shows a paucity of published data concerning the outcome of proximal humerus osteosarcoma managed by limb salvage. The purpose of this study was to answer the following questions: (1) do patients with proximal humerus osteosarcoma managed by limb salvage and neoadjuvant chemotherapy show good functional and oncological outcomes, and (2) are there any prognostic factors that are associated with better oncological and functional outcomes? The study was a retrospective case series study assessing the overall outcome of 34 patients with proximal humerus osteosarcoma. Eighteen patients were males (53%) while 16 were females. Biological reconstruction was done in 15 patients (44%), while nonbiological reconstruction was done in 19 patients. Resections were mainly intraarticular (82%). Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score, while oncological outcome was assessed based on local recurrence and development of chest metastasis. Comparisons between quantitative variables were done using the nonparametric Mann-Whitney test. To compare categorical data, the chi-square (χ2) test was performed. The exact test was used instead when the expected frequency was less than 5. Correlations between quantitative variables were examined using the Spearman correlation coefficient. The mean MSTS score was 25.5 (range 23-29). A younger age was statistically correlated with a poorer MSTS score (P = 0.0016). Six patients out of 34 (17.6%) had local recurrence and four of them (67%) were treated by forequarter amputation. 41% of patients developed chest metastasis, and the majority of them were treated by chemotherapy (71%). In comparison with patients with osteosarcoma at other sites who were also managed in our institution, proximal humerus osteosarcoma patients showed higher incidence rates of local recurrence and chest metastasis along with lower 5-year patient and limb survivorships compared to distal femur, proximal tibia and proximal femur osteosarcoma patients. Treatment of osteosarcoma of the proximal humerus by limb salvage and chemotherapy yields a good functional outcome. The method of reconstruction does not impact the resultant function. The 5-year survivorship of these patients is 65%. Younger patients have a better oncological outcome and an inferior functional outcome. Level IV therapeutic study.

High thoracic erector spinae plane block for forequarter amputation: A new perspective.

High thoracic erector spinae plane block for forequarter amputation: A new perspective.

Forequarter Amputation for Malignant Tumours: Tale of Sustained Relevance or Telltale Sign of Doom?

Forequarter amputation (interscapulothoracic amputation) includes surgical removal of an upper limb and the shoulder girdle, including the scapula and a portion of the clavicle. We aim to report about our recent experience of having to resort to this mutilating surgery and the clinicopathological variables in that context. The study was done at a cancer centre in Northeast India. It was an ambispective study design, where the patient cohort who underwent FQA was identified retrospectively from the operative register of major surgeries for the time period 1st June 2020 to 31st May 2022 (24 months), and these patients were followed up prospectively from 1st June 2022 to 31st May 2023 (1 year). The study variables were obtained from the electronic medical records (EMR), the physical case files and the hospital-based cancer registry (HBCR). There were 7 patients who underwent forequarter amputation (FQA) during the two years, and in the same period, 15 patients underwent limb salvage surgery for tumours around the shoulder girdle. This translates to a FQA rate of 31.8%. The male:female ratio of the patients was 3:4. The median age of the patients was 32 years (range 19 to 59 years). The histologies included osteosarcoma (2), chondrosarcoma (2), Ewing's sarcoma (2) and hidradenocarcinoma (1). None of these patients had any distant metastatic disease. Four patients had local disease progression on neoadjuvant chemotherapy. Three of the patients had emergency surgery as a life-saving procedure on account of bleeding from their ulcerated tumours. Two patients had disease which was recurrent and unsalvageable due to the encasement of the neurovascular bundle. The median follow-up was 8 months (range 4 to 18 months). Five patients had distant recurrence with pulmonary metastases (100%) and bone secondaries (14.3%) within a range of 3 to 8 months. None of the patients had any local recurrence. Two patients are on follow-up without any evidence of disease (17 and 18 months respectively). Forequarter amputation is the surgical option when tumours around the shoulder girdle are not amenable to limb-sparing procedures by virtue of their disease extent. These cancers are usually aggressive leading to early distant metastasis.

Reconstruction of Forequarter and Extended Forequarter Amputations: Indications and Outcomes.

Forequarter amputations (FQAs) and extended forequarter amputations (EFQAs) are rare procedures with high morbidity that often require significant soft-tissue or bony reconstruction. The authors describe the largest series of oncologic FQAs and EFQAs to date with associated reconstructive and oncologic outcomes. The authors retrospectively reviewed data from all patients who underwent FQA or EFQA at The University of Texas M. D. Anderson Cancer Center from January 1, 2008, to January 1, 2019. Surgical outcomes, survival, and local recurrence rates were summarized and compared. Forty-seven patients met the inclusion criteria, including 14 with EFQAs. Most patients (53%) were male; the median age was 58 years (range, 2 to 74). The most common tumor type was sarcoma (79%), and the most common presentation was recurrent (34%). Nineteen patients (40%) had distant metastases. The median defect size was 351 cm 2 ; flap reconstruction was required in 30 patients (64%). Eight patients (17%) experienced immediate complications and 12 (26%) experienced delayed complications. The median overall survival (OS) time was 21 months and the 5-year OS rate was 28.1%. OS and disease-free survival were superior in the EFQA group (69.8% versus 11.6%, P = 0.017; 58.9% versus 9.8%, P = 0.014, respectively). Metastasis at presentation was the most important predictor of survival on multivariate analysis (OR, 3.98; P = 0.004). Patients with EFQA had better OS and disease-free survival than did patients with FQA, owing to a lower incidence of metastatic disease. This study suggests a benefit to more aggressive resection and reconstruction when disease is locally confined. Therapeutic, III.

Vertical Rectus Abdominis Myocutaneous Flap for Reconstruction of Forequarter Amputation Defect after Shoulder Soft Tissue Sarcoma Resection: Technical Consideration

Summary: Forequarter amputations in advanced local malignancy or trauma cases often leave a large defect that is challenging to reconstruct. Options for defect closure are varied. A vertical rectus abdominis myocutaneous (VRAM) flap could be an alternative to close a significantly large defect, which is relatively easier than the more technically demanding free flap. This case presents a 64-year-old man with a soft tissue sarcoma in the left shoulder that was treated by forequarter amputation and subsequent defect closure using a VRAM flap. The VRAM flap was initially used to reconstruct the chest and abdominal walls. There have been no reported uses for the shoulder defect. The repair site defect was viable even with a less aesthetic donor site, and all of the defects were closed without any signs of infection. The VRAM flap is a good option for a large defect closure at the shoulder region, particularly after forequarter amputation.

718 Estimation of Total Body Surface Area Burns in a Bilateral Above-Knee Amputee Patient

Abstract Introduction The burn injury extension estimate is necessary for the initial IV fluid resuscitation planning, however, current Wallace rule of nines, Lund & Browder charts as well as smartphone applications are based anatomical models with full body integrity. The purpose of this paper is to accurately estimate the TBSA burned in a bilateral asymmetric above-knee amputee patient. Methods An amputation is defined as major amputation when the level is at or proximal ankle or wrist. We present a case example of an 80-year-old patient with a past medical history of long-standing type 2 diabetes mellitus with inadequate metabolic control, left above-knee amputation seven years ago, as well as a contralateral asymmetric above-knee amputation seven months before hospital admission. The patient was brought to the emergency department one hour after suffering burn injuries by fire at his shelter. Upon his arrival inhalational injury was ruled out, and at physical examination second and third-degree burns were noted circumferentially on both above-knee stumps, genitalia, right flank, lower abdomen and back, right hands and forearm, as well as left hand digits (Figure 1A-B). Initial TBSA burned was estimated using the E-burn application yielding a 27% extension; however, this percentage would correspond to patient with full integrity of both lower limbs (Figure 2A) Results This is the first major amputee burned patient of 285 cases admitted for in-hospital treatment at our institution from March 2020 to October 2022. After performing an online search on MEDLINE/Pubmed (keywords: TBSA, estimation, amputated) we found only one published paper in 2020 which presented a Correction Factor (CF) formula for a hypothetical burn patient with bilateral and symmetric fore-quarter amputation. We estimated the amputated surface area (13.7%) with e-burn, to calculate the major amputee CF published in 2020 and test it on a clinical setting. By means of the following formula (Figure 1C): CF = 100 / (100 - % of amputated body part) CF = 100 / (100 – 13.7) CF = 100 / (86.3) = 1.15 Finally, the initial TBSA burnt was multiplied by the CF to adjust it accordingly to major amputations of the patient, as follows: Originally estimated TBSA burnt (27%) x CF (1.15) = 31.05 % (Figure 2B-C) Conclusions This case report serves as an example of the clinical application of the Correction Factor for major amputees burn patients which can be easily estimated with the aid of smartphone applications such as e-burn in mismatched bilateral amputations. Applicability of Research to Practice To our knowledge this is the first clinical application of the major amputee CF, which its simplified estimation by means of E-burn could be of use for burn centers with higher volume.

Soft Tissue Reconstruction Using the Free Forearm Fillet Flap in the Salvage of Forequarter Amputations for Recurrent Sarcoma: A Report of 2 Cases.

Reconstruction after radical forequarter amputation for recurrent proximal extremity sarcoma is challenging because the defect is significant, and the axillary or subclavian vessels are resected with the tumor, indicating that the pedicle of nearby flaps is often cut off. Free flaps are commonly used to cover the defect, but the donor site morbidity is problematic. Another problem with resecting the axillary or subclavian vessels is difficulty obtaining recipient vessels with matching calibers for another free flap. The authors presented 2 cases that successfully solved all these problems by covering the defects by the forearm fillet flaps.The forearm fillet flap has the advantage of using a portion that is usually discarded, so there is no donor site morbidity. Moreover, using the brachial artery as the pedicle of the flap allows the anastomosis to the stump of the resected axillary or subclavian artery because differences in caliber are slight.The use of the forearm fillet flaps has been reported less frequently than the fillet flaps in the lower extremities, and most cases are posttraumatic. In cases of trauma, complications are reported to occur in about 1 in 4 patients, but in cases after tumor resection, ischemic time can be controlled, and there are no risks of contamination or unnoticed forearm damage, so more stable results can be expected as in this report.Using the free flap from the distal portion of the resected upper limb, especially in cases with a short prognosis, is a viable option that effectively minimizes damage to the donor site and maintains quality of life.

Management of Free Fillet Flap Transfers in Large Oncologic Resections

A retrospective review of the medical records of eight patients who underwent fillet flap reconstruction from 2013 to 2021 at Mayo Clinic, Arizona, were analyzed. Eight patients who underwent four hemipelvectomies, three forequarter amputations, and one below the knee amputation were identified. Patients' ages ranged between 24 and 66 years. All indications for oncologic ablation were curative. Defect sizes ranged from 16 × 20 to 30 × 60 cm. Four pedicled flaps and four free fillet flaps were performed. Indication for free fillet flap was tumor invasion of local vascular structures. There was no flap loss in the pedicled group (follow-up ranged from 1 to 9 years), and one of four free fillet flaps had a successful long-term outcome (follow-up 36 months). Successful free fillet flap reconstruction in the setting of oncologic resection is a difficult task to achieve. Changes to the management of case 3F allowed for a successful transfer. Immediate elevation and anastomosis of the flap before oncologic resection, large caliber recipient vessels and isolation from the zone of injury, protection of the anastomosis, and delay in flap inset all contributed to flap survival. It is our belief that applying these general considerations in large oncologic resections with free fillet flap transfer may aid in successful flap transfer and improve its survival odds.

Defect Coverage after Forequarter Amputation-A Systematic Review Assessing Different Surgical Approaches.

Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.

Recurrent malignant peripheral nerve sheath tumor presenting as an asymptomatic intravenous thrombus extending to the heart: a case report

BackgroundMalignant peripheral nerve sheath tumor (MPNST) is a rare soft tissue sarcoma mainly treated via surgical resection. Herein, we report a case of MPNST wherein a massive tumor thrombus extended to the major veins and heart.Case presentationA 39-year-old female with a history of neurofibromatosis type 1 developed MPNST from the right radial nerve. In addition to adjuvant chemotherapy, she underwent wide tumor resection and concomitant radial nerve resection, followed by postoperative radiotherapy. Histological evaluation revealed marked venous invasion. The 2-year follow-up CT revealed an asymptomatic recurrent tumor thrombus extending from the right subclavian vein to the heart. An urgent life-saving operation was performed to ligate the base of the right subclavian vein and remove the entire intravenous thrombus that extended to the right ventricle. The remaining tumor in the right subclavian vein increased in size 3 months after thrombectomy. After confirming the absence of any metastatic lesions, the patient underwent extended forequarter amputation to achieve surgical remission. One year later, a new metastasis to the right diaphragm was safely resected. The patient remains alive without any evidence of disease 2 years after the extended forequarter amputation.ConclusionsIn cases of a previous history of microscopic venous invasion, recurrence can occur as a massive tumor thrombus that extends to the great vessels.

Outcomes Of The Combined Anteroposterior Approach For Forequarter Amputation In Shoulder Girdle Tumours.

Forequarter amputation (FQA) is the surgical treatment of choice for tumours in the upper extremity and shoulder girdle that infiltrate the neurovascular bundle, shoulder joint and muscles of the shoulder girdle in non-salvageable cases. In both curative and palliative settings, FQA can serve as an effective oncological treatment for local control of tumour. All patients who underwent FQA in our unit from January 2016 till August 2019 for oncological indications were included in our study and their clinical outcomes were calculated. Thirteen patients were included in the study including 8 male patients. Mean age of patients at surgery was 20 years (Range 10-53 years) with a minimum follow up of 6 months or till patient was deceased earlier. Six patients had primary osteosarcoma, 4 had Ewing's sarcoma, 2 had Spindle cell sarcoma while 1 had Giant cell tumour. Six patients underwent surgery with curative intent. No major per operative complication was encountered in any of the cases with a mean blood loss of 350 ml and mean duration of surgery being 75 minutes. At last, follow up only 6 patients were alive, with 2 patients alive with disease (Metastasis) and undergoing palliative treatment. None of our patients had local recurrence. Mean survivorship for the whole cohort was 9.2 months (Range 3-18 months) with a mean survivorship for the deceased group was 7.1 months (Range 3-16 months) and mean survivorship for alive patients was 11.6 months (range 9-18 months). All the alive patients had phantom limb sensations and only one had a prosthesis in place only for cosmetic reasons, at last follow up. Although FQA is a significantly body disfiguring procedure, but in large tumours of shoulder girdle, this is a viable option for local control of the disease. Based on our study, although relatively small sample size, we propose the combined anteroposterior approach to be safe and reliable for advanced shoulder girdle tumours.

Indications and outcomes of palliative major amputation in patients with metastatic cancer

BackgroundPatients with stage IV cancer often experience diminished quality of life and pain. Although palliative amputation (PA) can reduce pain, it is infrequently performed because of the morbidity associated with amputation and the limited life expectancy in this population. Here, we describe the indications for PA in patients with stage IV carcinoma or sarcoma and discuss their clinical courses and outcomes. We hypothesized that PA would be associated with reduced pain and improved quality of life in these patients. MethodsWe retrospectively reviewed medical records of all patients who underwent major amputation (proximal to the ankle or wrist) for metastatic sarcoma or carcinoma from January 1995 to April 2021. We excluded patients who underwent amputation for indications other than palliation. Cox proportional hazards regression analysis was used to determine factors associated with survival after PA. ResultsTwenty-six patients underwent PA (11 for carcinoma, 15 for sarcoma). The most common indications for PA were pain (all patients) and fungating tumor (16 patients). PA was the initial surgery in 7 patients. Forequarter amputations were the most common procedure (6 patients). All patients reported reduced pain after PA, with the mean (±standard deviation) visual analog pain score (on a 10-point scale) decreasing from 5.7 ± 2.9 preoperatively to 0.43 ± 1.3 postoperatively (p < 0.001). The mean preoperative ECOG score was 1.9 ± 0.2 compared with 1.3 ± 0.1 postoperatively (p < 0.001). Fourteen patients were fitted for prostheses (6 upper extremity, 8 lower extremity). Two patients had local recurrence, both within 6 months after PA. The mean survival time after PA was 13 ± 12 months, and mean follow-up was 28 ± 29 months. Mean survival time after PA was not significantly different between patients with sarcoma (11 ± 11 months) versus carcinoma (15 ± 14 months) (p = 0.51). Adjuvant chemotherapy was positively associated with survival; no other factors were associated with survival. ConclusionsPA was associated with significantly reduced pain in all patients with stage IV cancer. PA should be considered for those with intractable pain, fungating tumors, or symptoms that diminish quality of life. Level of evidenceLevel III.

The Effectiveness of Saline Load Test in Detecting Simulated Traumatic Elbow Arthrotomies: A Cadaveric Investigation.

BackgroundThe saline load test has not been well explored in the elbow. We aimed to determine 1) the saline infusion volume needed for 90%, 95%, and 99% sensitivity in detecting elbow arthrotomy; and 2) factors associated with higher volume at detection using sixteen forequarter upper extremity amputation cadavers.MethodsSixteen fresh-frozen forequarter upper extremity amputations were procured, and demographic data, including age, body mass index (BMI), and laterality, were recorded. The olecranon process, radial head, and the lateral epicondyle were palpated, and elbow arthrotomy was consistently performed at the direct lateral arthroscopic portal site. The elbow joint was loaded with saline mixed with methylene blue (concentration: 2 mg/300 mL) using an 18-gauge needle inserted just medial to the triceps tendon 2 cm superior to the olecranon.ResultsMean volume for extravasation was 12.2 mL ±6.26. Volume needed for 90%, 95%, and 99% sensitivities were 21 mL, 23 mL, and 25.4 mL. Linear regression demonstrated that increasing age was associated with lower volume to extravasation (OR: 0.67; 95% CI: 0.48-0.932; p=0.037), while BMI (p=0.571) and extremity laterality (p=0.747) did not affect the volume.ConclusionsThe saline load test can be effective in diagnosing the violation of the elbow joint in traumatic injuries. This test should be used in conjunction with the clinical examination and radiographs before operative decisions are made. We recommend using ≥26 mL to rule out traumatic elbow arthrotomy.

Implant cement spacer-a cost-effective solution for reconstruction of proximal humerus defects after tumor resection

The proximal humerus is a common location for both primary benign and malignant bone tumors and may require sacrificing deltoid muscles, axillary nerve and/or rotator cuff along with proximal humerus resection. Thus, post operatively shoulder movements are restricted. The main goals of reconstruction are to maintain a stable shoulder so that the function of elbow and hand can be optimized. Various reconstruction options are available after proximal humerus resection. We present our experience in using implant-cement spacers as a primary reconstruction option for limb salvage in the primary tumors of proximal humerus. All cases were retrieved from our prospectively maintained surgical database. 142 patients (96 males and 46 females) with a median age of 17.5 years (3–70 years) were operated with implant cement spacer between January 2006 and April 2019. Median follow up was 34 months (1–174 months). Functional outcome of the surgery was assessed in survivors by Musculoskeletal Tumor Society score (MSTS). Implant survival was assessed by Kaplan Meier analysis and competing risk analysis. On last follow up, out of 142 cases, 81 patients had died, 54 are alive and seven were lost to follow up. 18(13%) patients underwent revision surgery for symptomatic proximal migration, implant failure or infection. Four (2.8%) patients underwent forequarter amputation for local recurrence. The five years implant survival (IS) by Kaplan Meier analysis was 79.6% and as per competing risk analysis, the chances of implant revision are 12% and 18% at five and ten years respectively. Mean MSTS score in survivors was 71% (60–80%). Implant cement spacer is a cost-effective alternative for reconstruction of proximal humerus with revision rates and function comparable to other reconstructions in cases where deltoid, axillary nerve and/or rotator cuff are excised.

Ventilatory failure in a cat following radical chest wall resection for feline injection site sarcoma

Case summaryA 12-year-old spayed female domestic shorthair cat presented for chest wall resection and radiation therapy following incomplete surgical excision of a feline injection site sarcoma. A CT scan for surgical planning was performed under general anesthesia and showed extensive tumor infiltration of the soft tissues of the right thorax. The cat recovered uneventfully from this anesthetic event. Nineteen days later, the patient was reanesthetized for forequarter amputation plus radical chest wall resection, including ribs 3–8 and all associated soft tissues plus adjacent spinous processes. Postoperatively, the patient developed acute respiratory failure secondary to hypoventilation. The cat was mechanically ventilated for 12 h prior to being successfully weaned from the ventilator. However, the improvement was transient and mechanical ventilation was reinitiated 6 h later owing to respiratory fatigue. On the second day, the cat developed unexplained central nervous system signs and was euthanized.Relevance and novel informationTo our knowledge, this is the first case report to describe ventilatory failure secondary to radical chest wall resection in a cat. Hypoventilation with subsequent need for mechanical ventilation is a potential complication that should be considered during preoperative planning in patients requiring extensive chest wall resections.

Targeted Muscle Reinnervation in Partial Hand Amputations.

SummaryTargeted muscle reinnervation (TMR) surgery has been shown to aid in prevention and treatment of neuropathic pain. Technical and anatomical descriptions of TMR surgery for upper extremity amputees (including transradial, transhumeral, and forequarter amputations) have been reported, yet such descriptions of TMR surgery for partial hand amputations are currently lacking. Herein we outline the technique of different types of partial hand amputation TMR surgeries to serve as a reference and guide. A retrospective review was performed by our multi-institutional team to identify clinical cases where partial hand TMR surgeries were performed. Patient demographics, characteristics, amputation subtype, nerve transfer, pain score, pain outcome, and functional outcome data were collected and analyzed. From January 2018 to September 2019, 13 patients underwent partial hand TMR procedures. Eight cases resulted from trauma, and 6 were secondary to oncologic procedures. The amputations consisted of 8 ray, 2 trans-metacarpal, 2 radial-sided hand, and 1 index finger amputation with recurrent painful neuromas. Twelve patients were weaned off narcotics completely and only 3 remained on a neuromodulator for ongoing pain control. Technical considerations for partial hand TMR surgery have been outlined, with early pilot data showing beneficial pain control outcomes.

Replantation of forequarter amputation: Report of two cases with successful structural, motor and sensorial results

Although there have been numerous reports of major replantation of upper extremity amputations, limited numbers of above-elbow amputation replantation have been reported. We present the technical details of two successful replantations of forequarter amputations in a nine-year-old girl and a three-year-old boy. In both cases, the forequarter was amputated due to avulsion traction injuries resulting in amputation including the entire upper limb, while the integrity of the scapula and parascapular muscles was maintained, with no injury to the glenohumeral joint. Replantation was performed, involving a shorter ischemia time with proper fixation, and vascular and neural repairs. Postoperative recovery was uneventful, and motor and sensorial acquisition were quite satisfactory during follow-up periods of 9 and 6 years, respectively. Proper fixation of the amputated part mimicking the original anatomy, radical debridement of avulsed vessels, and reconstruction of the defect using long vein grafts and neural repair while maintaining proper integrity are the most important factors in success. When the requirements are met, replantation of the forequarter in a child yields a superior outcome, from both the functional and esthetic perspectives. To the best of our knowledge, this is the first report in the English literature involving two sequential cases of such high-level replantation resulting in successful reacquisition of both viability and function.

638 Biodegradable Temporizing Matrix in Combination with Wide Meshed Graft and Autologous Spray Cell Suspension (ASCS) Graft Can be Used for Reconstruction of Extensive Necrotizing Infections: A Case Report

Abstract Introduction Background: A necrotizing infection of the left upper extremity underwent extensive debridement with remaining exposed muscle, tendon, and bone. BTM was used to provide an acceptable temporizing matrix in conjunction with wide meshed split thickness skin graft (STSG) 3:1 ratio and ASCS graft for successful reconstruction. This left a functional limb and avoided arm forequarter amputation. Methods Case Presentation: We present a 67 y/o male with necrotizing infection who underwent extensive surgical debridement of skin and subcutaneous tissues of the left hand, forearm, and upper arm. BTM was applied for coverage over muscle, tendon, and bone to salvage his arm and avoid forequarter amputation. Following maturation of the BTM a 3:1 ratio STSG was placed along with application of an ASCS graft. A vacuum assisted closure (VAC) dressing was successfully used to stabilize the grafts. One month post grafting the wound was approximately 94% healed, with good range of motion, and limited but improving function of his arm. Results Conclusion: Necrotizing infection extremity reconstruction can be achieved with BTM, wide meshed STSG, and autologous ASCS grafting. A wound VAC provided a safe and effective dressing over these grafted mediums. Conclusions Conclusion: Necrotizing infection extremity reconstruction can be achieved with BTM, wide meshed STSG, and ASCS epidermal autograft. A wound VAC provided a safe and effective dressing over these grafted mediums.