Forequarter Amputation Research Articles

A Tool to Strengthen the Doctor-Patient Relationship

Though Congress passed the American Recovery and Reinvestment Act earlier this year, debate continues to swirl around the provision of funds for comparative effectiveness research. Critics warn that government bodies could use such research to dictate appropriate care and impose third-party oversight so intrusive it would impinge upon the interaction between doctors and their patients. On the contrary, I believe that comparative effectiveness has the potential to strengthen the patient-doctor relationship. How? By keeping all of us from being blindsided by our own best intentions. Dr. G was a senior surgeon and teacher of mine. What set Dr. G apart from his colleagues was an extraordinary ability to sympathize--empathize, even--with his patients. As I trailed him on rounds, I watched him, a former college football player, fold his body into a small bedside chair in order to better listen as patients spoke. With certain patients he seemed so moved that his emotions reflected theirs perfectly. He smiled when they did; his eyes welled up as great tears fell from theirs; his face flushed with anger when they spoke of mistreatment by another clinician. Once outside the room and unlike some of his other colleagues, Dr. G's sentiments did not evaporate. Instead, he translated them into care so conscientious that he routinely put the efforts of younger and more energetic doctors to shame. For a young surgeon who wanted more than anything to retain all of my compassionate ideals beyond my training, Dr. G was a beacon of light at the end of a very long tunnel. He represented what I someday hoped to be. Until I saw him care for Carolyn. Carolyn was stay-at-home mother who had been diagnosed with inflammatory breast cancer, a rare but extremely aggressive tumor. Her primary care doctor had used the term locally in his referral note; but his descriptor, we would soon learn, put it mildly. Carolyn's left breast was covered with fungating, necrotic tumors. One of the tumors extended upwards, throwing off pebble-sized satellite lesions that burrowed into her left shoulder. Left uncovered, the tumors reeked of rotting flesh, an odor so strong that the doctors and nurses in the clinic's hallway donned surgical masks. In Carolyn's room, the other resident and I tried to keep our breathing shallow. Dr. G, however, remained unphased, sitting next to Carolyn for half an hour and touching her tumors with ungloved hands. He asked questions and listened quietly as she responded. He nodded when she talked about her children and frowned when she recounted her failed attempts at radiation therapy and the less-than-fruitful discussions with medical oncologists who had thrown up their hands. I watched Dr. G begin to lean forward as he heard about the other doctors who had turned their backs on Carolyn. I could see lines appear on his forehead as his lips pursed together in deep thought. Then I heard Carolyn's final entreaties. Could he as a surgeon do something? Could he operate and take all the tumor away? Dr. G stood silent, looking for a moment like a man suddenly thrown in turbulent waters and struggling to keep afloat. The look soon passed, his brow smoothed over, and, looking straight into Carolyn's eyes, he answered quietly, Yes, we can. He passed his hand once more over the tumorous terrain of her left chest and shoulder. We would have to do a mastectomy and a forequarter amputation. That is, we would need to amputate your arm and your shoulder because the tumor extends all the way there. He paused again, then added, You would lose your arm, but we would take all that tumor away. I looked at the other resident. The muscles along his mandible had tightened; this was the only thing that prevented his jaw from dropping. Both of us knew that such radical surgery was unheard of in patients with advanced inflammatory breast cancer. But we also knew that there was no comparative effectiveness research available on aggressive surgical therapy with this disease. …

Perioperative Haemorrhage and Transfusion in Musculoskeletal Tumour Surgery.

Background and Objectives: Musculoskeletal tumor surgery in the West African subregion is rapidly evolving. These procedures are associated with significant blood losses necessitating large amount of transfusion, of which there is inadequate documentation. Allogeneic blood transfusion has been associated with increased recurrence of malignancies and is fraught with various complications. This study is aimed at evaluating the blood loss and transfusion requirements in various musculoskeletal tumor surgeries at a tropical Orthopedic Oncology unit. Method: A prospective study was conducted in patients with musculoskeletal tumors, undergoing surgery over a 5 year period. 74 procedures were performed in 58 patients and data such as age, sex, tumor type, surgical procedure, total blood loss, amount of blood transfused and attendant complications were retrieved. Results: The age range of the patients was 7 to 85 years with a mean age of 26.1 years. [M:F ratio 1.6: 1]. Surgery for benign bone tumors accounted for 55% of the procedures performed, while primary malignant lesions were the diagnosis in 41% of cases. Surgery was performed for secondary malignant tumor in 4% of cases. Tourniquet use was possible in only 36% of the surgeries, and the operation time range from 42 to 184 minutes [mean 67.5 minutes]. The range for total blood loss was 5 to 4950 mls. The mean blood loss was more for extensive procedures such as, forequarter amputations, above knee amputations, and resection / reconstruction. There was significant correlation between the total blood loss and the operation time. Blood transfusions were required in 57.1% of the surgeries and the total number of units transfused range from 0 to 4500 mls. The early complications of blood transfusion noted in these patients include, febrile reaction [33%], malaria fever [21%], hemolytic reaction [6%]. Conclusions: Blood loss in Orthopaedics musculoskeletal tumour surgery is significantly high, warranting large amount of blood transfusion. Adoption of standard blood management strategies by individual units, the use of autologous blood transfusion, and recombinant erythropoietin may reduce the attendant complications associated with blood transfusion. Nigeria Journal of Orthopaedics and Trauma Vol. 7 (2) 2008: pp. 63-65

외상성 견갑 흉곽간 절단 - 증례 보고 -

Traumatic forequarter amputation is an extremely rare and life-threatening injury. It is caused by blunt trauma or tremendous traction force, and the prognosis is very poor because of the involvement of massive associated injury. Traumatic forequarter amputation has been rarely reported in the English language clinical literature, but has never been reported in Korea. We report a case of traumatic forequarter amputation caused by a conveyor belt that was treated with emergency resuscitation and surgery, with an accompanying review of the literature.

Traumatic Forequarter Amputation Complicated With Transient Horner Syndrome: Case Report

Traumatic Forequarter Amputation Complicated With Transient Horner Syndrome: Case Report

Management of Giant Cell Tumour: A Nigerian Experience

Giant cell tumours (GCT) are the commonest bone tumours worldwide. It is rarely malignant but when it does it progresses to fibrosarcoma with high mortality. Otherwise it causes poor cosmesis, disability and pathological fractures. A total of 19 cases of histologically established Giant cell tumour of the bone were reviewed prospectively in a 5 year study. 14 cases were benign, 4 malignant and one was a malignant transformation. Lesions around the knee accounted for 42.2% of the cases, but the radius was the commonest single bone affected with 26.3%. Eleven patients had curettage, five of them had autogenous bone grafting while the remaining six had bone grafting and plate augmentation. One patient had fore-quarter amputation while seven had tumour resection. There was no recurrence recorded among those that had currretage and autogenous bone grafting. 33% of those that had curettage and bone cementing as well as 16.6% of those that had resection presented with recurrence. One patient died within 3 months of surgery due to metastasis to the lungs, liver and spleen. Mean follow up was 9.2 months (range of 2 to 60 months). With early presentation, curretage and bone grafting is often effective; late presentation however has an increased risk of recurrence due to soft tissue involvement, dearth of investigative tools and financial constraints. Nigerian Journal of Surgical Sciences Vol. 17 (2) 2007: pp. 91-95

Brachial Plexus Neuroma Mimicking Local Recurrence of Malignant Mesenchymal Tumor After Forequarter Amputation

A stump neuroma is an attempt for the repair of a nerve following amputation. This article presents a case of a 60-year-old woman who was suspected of having a local recurrence on the chest wall following amputation of the left arm for a malignant mesenchymal tumor. The tumor did not show any invasion to adjacent structures thereby any necessity for chest wall resection and reconstruction. The patient underwent local excision of the tumor with reamputation of the branches of the lower brachial plexus, subclavian artery, and proximal one third of the clavicle. The tumor was eventually diagnosed as a brachial plexus neuroma. Although rare, cases that require left pneumonectomy with a transthoracic forequarter amputation including brachial plexus resection have been reported. Transection of the brachial plexus also may be needed during resection of a superior sulcus tumor. These cases often undergo an aggressive chest wall resection that includes the subclavian artery and vein in addition to the brachial plexus, particularly in tumors involving the lower truncus. Therefore, when recurrent chest wall tumor is suspected in such cases, stump neuroma resulting from transection of the brachial plexus should be included in the differential diagnosis.

Zur Selbsteinschätzung der Lebensqualität von Tumorpatienten nach Amputation der Hand

Amputation proximal to the wrist may be oncologically dictated in cases of upper extremity soft tissue sarcoma and aggressive fibromatosis. Literature on functional long-term results and patient-oriented assessment is sparse. Our study is concerned with subjective impressions of quality of life and upper extremity health status and their importance in the evaluation and interpretation of results after amputation of the hand. Between 1999 and 2007, 14 patients (6 females/8 males; average age: 25 years) were operated because of a soft tissue sarcoma (n = 11) or aggressive fibromatosis (n = 3). Ten patients underwent limb-sparing surgery. There were two amputations at the level of the forearm. Local recurrence following forequarter amputation due to aggressive fibromatosis required reoperation in another patient. A heterotopic replantation after resection was carried out in one patient. In patients with amputations, the self-reported upper extremity-specific health status and quality of life were measured with the DASH score. Disturbances in body image and symptoms of depression were assessed psychiatrically. In two cases with amputations, minimal impairments in everyday life and a high reported quality of life were observed (DASH scores: 3,5). Self-reported upper extremity health status and quality of life following amputation of the hand can be in contrast to the objective pathology. In patient-oriented assessment of results, individual psychosocial factors that may affect results must be taken into consideration. They also must not be neglected when determining whether patients are suitable candidates for prosthetic devices.

Large Tumors of the Axilla

Tumors of the axilla are rare and pose a surgical challenge because they are usually large at presentation and in close proximity to the major neurovascular bundle of the upper extremity. The use of detailed preoperative evaluation studies and extensile surgical exposure for these tumors enabled us to determine tumor resectability and proceed with a safe resection or perform an amputation when required. We retrospectively reviewed 27 patients who underwent resection of an axillary tumor from 1989 to 2004 and analyzed their presenting symptoms, results of preoperative studies, type of surgery, and functional outcome. Tumors were exposed using a utilitarian shoulder approach that revealed no tumor invasion of the neurovascular bundle in 19 patients and invasion in eight. The former group was treated with tumor resection and the latter with forequarter amputation. Neurologic deficit, limb edema, and angiographic observation of arterial narrowing were associated with amputation. Good function was achieved in 15 of 19, shoulder range of motion was preserved in 14 of 19, and local tumor control was maintained in 16 of 19 patients who underwent a limb-sparing resection.

Forequarter amputation for malignant tumours of the upper extremity: Case report, techniques and indications

Forequarter (interscapulothoracic) amputation is a major ablative surgical procedure that was originally described to manage traumatic injuries of the upper extremity. Currently, it is most commonly used in the treatment of malignant tumours of the arm. With the advent of limb-sparing techniques, primary forequarter amputation is performed less frequently, but remains a powerful surgical option in managing malignant tumours of the upper extremity; therefore, surgeons should be familiar with this procedure. A classic case report of forequarter amputation, with emphasis on indications and surgical techniques, is presented.

Innere Amputation einer oberen Extremität mit zerebraler Perfusionsstörung und letalem Ausgang

An inner amputation of the upper extremity is understood to be a rupture of the arm's vascular nerve bundle as well as the shoulder's and scapular's stabilizing muscles and fibrous joints without damage to the dermal soft tissue sheath. This injury is a rare and grave incident which mostly occurs within the scope of a high-energy trauma and in cases of polytraumatized patients in combination with additional life-threatening injuries. In the literature this is referred to by the terms scapulothoracic dissociation (SD) and closed forequarter amputation--the entity of SD was first described by Oreck et al. in 1984. Traction of the upper extremity leads to the rupture of the m. pectoralis major, m. pectoralis minor, the musculi rhomboidei, the m. levator scapulae, the m. latissimus dorsi as well as the m. trapezius. Furthermore the traction causes acromioclavicular or sternoclavicular bursting of the joints or a displaced clavicle fracture. Among the more than 50 cases depicted until now, 94% of the patients exhibit a neurological (plexus) and 80% a vascular lesion, thus corresponding to a genuine inner amputation. The prognosis for this injury is consistently poor: 10% of the patients die, in 52% an nonfunctional extremity remains, and in 21% a untimely amputation has to be performed. The observed complication of cerebral hypoperfusion caused by increasing pressure in the neck compartment, which ultimately leads to the death of the patient, has, as far as we know, not yet been specified and emphasizes the gravity and the magnitude as well as the necessity of rapid diagnosis and appropriate therapy of this infrequent injury.

Major extremity amputation for nodal metastasis from squamous cell carcinoma

The regional lymph node basin is usually the first site of spread in cutaneous squamous cell carcinoma (SCC). Regional metastases are usually treated with comprehensive nodal dissection, sometimes followed by radiation and/or chemotherapy. Occasionally, when disease recurs after these conventional therapies, major extremity amputation may be the only way to render patients free of disease. We present three cases for which major extremity amputation was necessary. One patient underwent forequarter amputation for nodal metastasis, which had invaded the brachial plexus. Another patient underwent hip disarticulation for femoral bony invasion from inguinal nodal metastasis. The third patient underwent a hemipelvectomy for nodal metastasis, which had eroded the femoral artery and pelvic bone. These cases show that major extremity amputation can be both palliative and curative in patients with SCC.

Radiation-induced soft-tissue sarcoma.

Twenty patients with soft-tissue sarcomas arising within previously irradiated fields have been analysed. The initial radiation dose ranged from 8.8 to 70 Gy, comprising either orthovoltage or megavoltage treatment. The latent interval following radiotherapy ranged from 7 to 45 years (mean 16.8 years). The commonest histological subtype was malignant fibrous histiocytoma. Four patients required forequarter amputation. The 5-year survival was only 14 per cent. The high morbidity and mortality accompanying post-radiation sarcomas must be borne in mind when the choice between therapeutic options for potentially curable cancers is finely balanced.

The forequarter amputation. By H. F. Moseley, M.A., D.M., M.Ch., F.R.C.S., F.A.C.S., Hunterian Professor, Royal College of Surgeons of England; Assistant Professor of Surgery, McGill University, Associate Surgeon, Royal Victoria Hospital, Montreal, Canada. 11 × 8 3/4 in. Pp. 79 + viii, with 25 illustrations and 11 colour plates. 1957. Edinburgh and London: E. & S. Livingstone Ltd. 42s

The forequarter amputation. By H. F. Moseley, M.A., D.M., M.Ch., F.R.C.S., F.A.C.S., Hunterian Professor, Royal College of Surgeons of England; Assistant Professor of Surgery, McGill University, Associate Surgeon, Royal Victoria Hospital, Montreal, Canada. 11 × 8 3/4 in. Pp. 79 + viii, with 25 illustrations and 11 colour plates. 1957. Edinburgh and London: E. & S. Livingstone Ltd. 42s Get access The Forequarter Amputation. By H F Moseley, M.A., D.M., M.Ch., F.R.C.S., F.A.C.S., Hunterian Professor, Royal College of Surgeons of England; Assistant Professor of Surgery, McGill University, Associate Surgeon, Royal Victoria Hospital, Montreal, Canada. 11 × 8 3/4 in. Pp. 79 + viii, with 25 illustrations and 11 colour plates. 1957. Edinburgh and London: E. & S. Livingstone Ltd. 42s. British Journal of Surgery, Volume 45, Issue 192, January 1958, Page 396, https://doi.org/10.1002/bjs.18004519224 Published: 06 December 2005

Limb conservation for soft tissue sarcomas of the shoulder and pelvic girdles.

Fifty-five patients with soft tissue sarcomas of the shoulder and pelvic girdles were treated between 1982 and 1987 with a consistent policy of limb conservation, using a wide variety of excisional and reconstructive surgical techniques and radical radiotherapy. Actuarial 5-year overall survival was 75 per cent for patients with low or intermediate grade tumours, and 38 per cent for those with high grade tumours (log rank test, P less than 0.05). Five-year local recurrence rates were 32 per cent for low or intermediate grade tumours, and 48 per cent for high grade tumours (log rank test, not significant). Multivariate analysis of the following risk factors for overall survival was performed: age, sex, tumour site, diameter, grade, inadequate surgical margins and local recurrence. Age over 55 years and high tumour grade emerged as independent prognostic variables for survival. Forequarter or hindquarter amputations were undertaken in seven of the 55 patients for local recurrence following previous limb-conserving surgery and radiotherapy. Local failure was not always salvaged by major amputation; satisfactory proximal tumour clearance was achieved in only two of seven patients undergoing major amputation; four of the seven patients developed stump recurrence, three of whom died with uncontrolled local disease. Meticulous attention to surgical and radiotherapeutic technique is required to minimize the incidence of local recurrence while maintaining satisfactory limb function.

Chondrosarcoma of the proximal humerus in a cat

Chondrosarcoma of the proximal humerus was diagnosed in a four-year-old, castrated male, domestic shorthair cat that was presented with a slowly growing solid mass in the region of the proximal humerus. Forequarter amputation was advised, but declined by the owners. Following surgical debulking clinical signs resolved, but two months after surgery the cat was readmitted because the mass had recurred in the same region. The forequarter was amputated. Histopathological evaluation of the tumour confirmed the diagnosis of chondrosarcoma. Follow-up examinations performed over a period of 15 months from initial presentation revealed that the cat was doing well and had no signs of metastatic disease. To the authors' knowledge, this is the first reported case of chondrosarcoma of the proximal humerus in a cat to be diagnosed and surgically treated. This case demonstrates that animals with such tumours may recover well after complete excision.

Chondrosarcoma of the scapula

Chondrosarcoma is the second most common primary sarcoma of bone. It often develops within flat bones, such as the pelvis, ribs, and scapula. In the current study, the authors reviewed the surgical experience and long-term oncologic outcomes of patients with chondrosarcoma arising in the scapula. The medical records of 29 consecutive patients with chondrosarcoma of the scapula were reviewed. The patients were treated between 1954 and 1994. All patients had localized disease at the time of presentation. The tumors were classified histologically as Grade 1 (10 patients), Grade 2 (10 patients), Grade 3 (7 patients), dedifferentiated (1 patient), and mesenchymal (1 patient) (using the criteria of Evans et al.). The mean maximal dimension of the tumors was 11 cm. Twenty-five patients underwent limb-sparing surgical resection and 4 patients underwent forequarter amputations. The median follow-up was 13 years (range, 1-35 years). At last follow-up, 22 patients (76%) were free of disease and 7 patients (24%) had died of their disease. Local recurrence occurred in 4 patients at 7 months, 16 months, 40 months, and 43 months, respectively. The local recurrence-free survival rate was 86% at 5 years, 10 years, and 20 years. Disease-specific survival was 83% at 5 years, 74% at 10 years, and 74% at 20 years. Patients who had low-grade chondrosarcomas had better survival compared with patients who had high-grade chondrosarcomas (P = 0.07). Patients who had localized chondrosarcoma of the scapula had a favorable long-term outcome, most likely due to the unique anatomic features that improved the likelihood of achieving wide surgical margins with limb-sparing surgery, despite the frequent presentation of locally advanced disease.

Forearm fillet flap for defect closure after chest wall resection in a breast cancer patient after forequarter amputation

BACKGROUND: Widespread local recurrence of breast cancer and extension to the chest wall and other nearby structures in patients after radio- and chemotherapy is not rare. Recurrence might be associated with ulceration and severe pain after radiation therapy. Paralysis of the arm might result from compression of the brachial plexus. METHODS: We report here on a breast cancer patient in whom chest wall resection to deal with tumor invasion was followed by reconstruction undertaken with a flap raised from the forearm of the amputated upper extremity which had been paralysed by tumor extension. RESULTS: The patient was reintegrated into family life, thus saving her from social isolation and psychological suffering caused by her stinking ulcer. In addition, her extreme physical suffering was ameliorated to a great degree despite accompanying mutilation. CONCLUSIONS: Palliative forequarter amputation, chest wall resection, and subsequent chest wall reconstruction might be considered in patients without detectable metastases for improving the patient’s quality of life, even though it may not be curative and chances of long-term survival may be poor. The patient, however, must find the price of severe mutilation acceptable.

An Internet-Based Referral/Consultation System for the U.S.-Associated Pacific Islands: Its Contribution to Orthopedic Graduate Medical Education at Tripler Army Medical Center

To evaluate the benefit of the Pacific Island Health Care Project (PIHCP) to our orthopedic graduate medical education program, we performed a retrospective review of our 8-year operative experience with patients referred through this program. Between July 1994 and June 2002, 69 patients underwent 79 orthopedic operative procedures. Patients were categorized by primary diagnosis, anatomic site involved, and surgical treatment rendered. Because many of the patients referred from the PIHCP with tumors were noted to have either unusually large lesions or advanced-stage disease, further analyses of tumor stage and pathologic grade were made. Seven of the 14 oncologic cases surgically treated in our department in the past 8 years were referrals from the PIHCP. Unique operative procedures performed for these tumor patients included one forequarter amputation, one hip disarticulation, one hemipelvectomy, two partial scapulectomies, and one distal ulna excision. We conclude that the PIHCP referrals provide an important and relatively unique contribution to the clinical and operative experience of our orthopedic residents. These patients from the Pacific basin also enhance our orthopedic graduate medical education program by exposing our residents to the special socioeconomic and cultural issues related to caring for people from developing insular countries.

Improved shoulder contour following forequarter amputation with an osteomyocutaneous free flap from the amputated extremity: two cases

To cover a large soft-tissue defect and to reconstruct the shoulder contour after forequarter amputation, we used an osteomyocutaneous free flap incorporating an elbow joint from the amputated extremity in two patients. These flaps were well vascularised and reliable. They provided excellent coverage of large soft-tissue defects and they maintained shoulder contours. This procedure is useful for reconstruction after extended forequarter amputation and chest wall resection.

Forequarter amputation for recurrent breast cancer: A case report and review of the literature

Axillary recurrence of breast cancer is an uncommon event that can lead to debilitating pain, lymphedema, and paralysis of the upper extremity. Multimodality therapy including surgery is usually used to control local recurrence. In a subset of patients, the extent of disease is such that local excision of the recurrence is not possible. In the absence of metastatic disease, forequarter amputation may be used as an effective means of surgical salvage and palliation for locally recurrent breast cancer. In this report, we describe management of a patient with advanced axillary recurrence treated with forequarter amputation and review the current literature on the use of this operation in breast cancer patients.