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Claviculectomy has been described for primary or metastatic tumors of the clavicle. In 11 patients, claviculectomy was used as a technical expedient for the exposure and en bloc resection of large, underlying nodal metastases from melanoma (7 patients) and soft tissue tumors (4 patients). There were no wound complications. Three patients developed moderate edema of the arm. There was little limitation at the shoulder, and the use of the upper extremity has been essentially normal. Claviculectomy is well tolerated, provides good exposure of the underlying neurovascular structures, and, in some patients, provides a method of limb salvage for underlying tumors in preference to forequarter amputation.

For Paul Kanulambi Walelu, dealing with gunshot wounds, open fractures, emergency caesarean sections, peritonitis, and typhoid perforations is all in a day’s work. Or, quite often, all in a night’s work. For as well as working seven days a week, Mr Walelu, an anaesthetic nurse, works every other night, for the medical aid organisation Medecins Sans Frontieres at the busy Rutshuru Hospital in North Kivu, the war-torn province on the eastern border of the Democratic Republic of Congo. It is Mr Walelu who in October last year helped the British surgeon David Nott in a forequarter amputation on a 16 year old boy who was close to death ( BMJ 2008;337:a2958, 10 Dec, doi:10.1136/bmj.a2958). The boy had previously had an operation to remove the upper part of his arm, but his stump was septic and gangrenous when Dr Nott arrived for a month’s voluntary service at the hospital. …

The two surgeons who, 7000 km apart, collaborated by text to successfully perform a forequarter amputation highlights how detailed expert operative information can be provided and transmitted to any part of the world.1 Since 2001, one of us (MHE) has been writing …

Traumatic forequarter amputation is a rare and very devastating injury. The arm, including the scapula, clavicle, and pectoral muscle, is torn from the body by a tremendous traction force, usually combined with a counteracting force from the body. The cases of three patients are presented. One patient was caught by the axle of a harvesting machine, resulting in a forequarter amputation of his right extremity and amputation of his left arm at the level of the upper arm. The other two patients had their arms caught in conveyer belts. All patients survived. Closure of the defect was performed acutely using a local pedicled musculocutaneous flap in one case and free vascularized musculocutaneous flaps from the amputated limbs in the two other cases.

A retrospective review of all malignant hand tumors seen at the University of Michigan from 1950 to 1987 demonstrated six biopsy-proven cases of neurofibrosarcoma involving the upper extremity. There were four male and two female patients; average age at presentation was 37 years and ages ranged from 15 to 63 years. All patients had a history of von Recklinghausen's disease. Three patients were seen initially with painful enlarging masses, one with a painful mass with a neurological deficit, and two with painless enlarging masses. Three patients had radical excisions requiring upper extremity or forequarter amputation, and three patients received limited or no surgical treatment. Five patients died of metastases an average of 3 years after diagnosis. One patient remains alive 18 years after upper extremity amputation despite an early local recurrence. Early diagnosis and radical surgical excision offer the best chance of long-term survival from this highly lethal cancer.

The surgeon David Nott, a Christian who does regular voluntary work abroad, made headlines last week when he recounted how he used instructions sent by text message to do a forequarter amputation on a boy in the Democratic Republic of Congo. Here he tells the story in his own words

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.

The Tikhoff-Linberg procedure is a limb-sparing surgical option to be considered for bony and soft tissue tumors in and around the proximal humerus and shoulder girdle. The authors reported 6 cases of the Tikhoff-Linberg procedure for tumors around the shoulder joint at the Department of Orthopedic Surgery of Severance Hospital from March 1988 to May 1989. The results of the study are as follows: The 6 cases were composed of: osteogenic sarcoma 2 cases, chondrosarcoma 2 cases, chondroblastoma 1 case, and giant cell tumor 1 case. The tumors were completely removed by the Tikhoff-Linberg procedure without amputation or disarticulation of the upper extremity. The distal clavicle, upper humerus and part of all of the scapula were resected. The Tikhoff-Linberg procedure was performed for patients whose tumors did not involve the neurovascular bundle in the axilla. The function of the hand and forearm after the Tikhoff-Linberg procedure was nearly normal in all cases. The Tikhoff-Linberg procedure would be recommended as a limb-sparing operation for tumors around the shoulder joint that require wide resection without disarticulation or forequarter amputation of the upper extremities.

Dramatic change has been seen in the treatment of shoulder girdle neoplasia. Forequarter amputation was once the treatment of choice for aggressive tumors in this area. Today, the great majority of shoulder girdle malignancies are treated with limb-sparing procedures like the Tikhoff-Linberg resection, which involves removal of the scapula, humeral head, outer third of the clavicle, and surrounding soft tissues. With advancements in surgical and endoprosthetic technology, expectations of surgeons and patients have increased and limb preservation without reasonable function is no longer acceptable. Since en bloc total scapular and proximal humeral resection can leave a flail upper extremity, the goal of modern skeletal reconstructions is to maintain near normal hand and elbow function by stabilizing the shoulder. The most recent techniques also attempt to restore some shoulder function. Published reports documenting these notoriously difficult procedures and their post-operative imaging findings are scarce. This is an educational exhibit designed as a Web site containing didactic text and numerous operative photographs, plain film, CT, and MR images, as well as patient videos. Viewers will navigate the site using a toolbar located on each page that contains links to pages including prevalence of shoulder neoplasia, relevant shoulder anatomy, mechanisms of tumor spread, historical therapeutic perspectives, surgical options, surgical indications, operative techniques, methods of reconstruction, implant types, pre- and post-operative imaging findings, and patient functionality based on the series from our institution.

The neutropenic state characteristic of acute lymphoblastic leukaemia (ALL) predisposes to infections involving Gram-negative bacilli. An Escherichia coli cellulitis originating in the first web space of the hand is described in a patient undergoing reinductiori chemotherapy for ALL. Proximal extension of the infection progressed at a very rapid rate and required a forequarter amputation as a life saving measure. Due to the blunted inflammatory response in neutropenic patients, the need for close monitoring and quick intervention is stressed.

Post girdle excision (forequarter amputation and hemi-pelvectomy) for bone or soft tissue tumours result in extensive defects exposing bone and major neurovascular structures. Large flaps are necessary to reconstruct the defect and protect the underlying structures. Total thigh flap was first described in 1956 by Georgiade et al. for the treatment of large trochanteric ulcers with osteomyelitis of femur. Free fillet flaps from the amputated limb provides a large amount of soft tissue coverage without additional donor site morbidity and hence it is ideal in major reconstruction for these trunk defect. We had five patients with major excision of girdle tumour with two forequarter amputation, three hemipelvectomy (two osteosarcoma, three soft tissue sarcoma). Four fillet limbs were used (two upper limbs, two lower limbs, one multiple local transposition flaps). The clinical course, morbidity and mortality were discussed in this paper.

Objective To evaluate complications and the oncological and intermediate-term functional results in patients with bone and soft tissue tumors of the shoulder girdle who were managed with interscapulothoracic resection (Tikhoff-Linberg procedure). Design Case series of 19 consecutive patients during a 10-year period at a mean follow-up of 6.3 years (range, 1-11 years). Setting University hospital; referral center for musculoskeletal tumor surgery. Patients The initial diagnosis in this consecutive series of patients with shoulder girdle tumors requiring the Tikhoff-Linberg procedure was chondrosarcoma in 7 patients, Ewing sarcoma in 3 patients, malignant fibrous histiocytoma in 3 patients, solitary metastasis of thyroid carcinoma in 2 patients, osteosarcoma, synovial sarcoma, angiosarcoma, and neurofibrosarcoma in 1 patient each. According to the Musculoskeletal Tumor Society staging system, there were 6 in surgical stage IB, 10 in stage IIB, and 3 in stage III. Nine tumors involved the proximal humerus, 8 were located in the scapula or surrounding soft tissues, 1 in the lateral clavicle, and 1 in the acromioclavicular joint. Interventions For reconstruction of the proximal humerus after en bloc tumor resection an isoelastic cemented shoulder tumor prosthesis was inserted in every patient to restore arm length. Main Outcome Measures Complications, and oncological and intermediate-term functional results. Results Twelve patients were alive with no evidence of disease. One of these patients died of nontumorous disease 2 years after surgery. One patient is alive with pulmonary metastases after 12 months. Six patients died of metastases at a mean (SD) interval of 18 months (range, 3-35 months) postoperatively. Two of these patients had additional local recurrence. A deep infection necessitated the explantation of the prosthesis in 1 patient. The mean functional score and SD according to the rating system of the Musculoskeletal Tumor Society was 72%±14% (range, 33%-87%) for the 12 surviving patients evaluated. Major complications (1 infection and 2 local recurrences) that may be attributed to the procedure occurred in 3 of the 19 patients. Conclusion Despite an overall complication rate of 74% the Tikhoff-Linberg procedure proved to be a valuable surgical procedure for extended tumors of the shoulder girdle for functional and oncological outcome and is superior to forequarter amputation.

This study reviews 16 cases of lymphangiosarcoma of the upper extremity after mastectomy for breast cancer (Stewart-Treves syndrome) was done at the author's institution from 1970 to 1992. Lymphangiosarcoma was diagnosed an average of 10.6 years (range, 5.6-18 years) after the diagnosis of breast cancer. Presenting signs included a bruise (6 patients); increased swelling (4); a red, raised lesion (2); a palpable mass (2); a blister appearance (1); and a non-healing eschar with continual bleeding (1). After biopsy, surgical treatment included forequarter amputation (8 patients), wide excision with grafting (5), and above-elbow amputation (1). Local recurrence of the lymphangiosarcoma occurred on the chest wall in 11 of the 16 patients after an average of 10.9 months. Metastasis occurred in 11 patients. (Metastasis occurred in 1 patient without local recurrence, and 1 patient with locally recurrent lymphangiosarcoma died of breast cancer before evidence of metastatic lymphangiosarcoma.) There are 2 long-term survivors who have lived 9.3 and 6 years, respectively, since the operation. One had been treated with a forequarter amputation and the other with wide excision. Early recognition and surgical treatment seem to offer the only chance for long-term survival.

This report represents a case of high-pressure hydrochloric acid injection of the shoulder girdle, with the resultant need for aggressive debridement in the form of extended forequarter amputation. The accelerated destructive activity of such reducing agents and the need for neutralization or removal of these agents is emphasized. Debridement, copious saline irrigation, and careful periodic monitoring are recommended.

Over a 17-year period, 56 patients with 57 tumors involving the brachial plexus were operated upon. The 40 neural sheath tumors included 26 neurofibromas, 8 schwannomas, 4 malignant neural sheath tumors, 1 fibrosarcoma, and 1 meningioma. Nine of the neurofibromas were associated with von Recklinghausen's disease (VRD), and 2 others were what was termed regionalized neurofibromatosis characterized by involvement of one limb with extension along the course of one or more plexus elements. Seventeen tumors were not of neural sheath origin; 7 were benign and 10 were metastatic malignant tumors compressing or invading the plexus. Benign neurofibromas and malignant sheath tumors almost always presented with pain or functional neural deficit, whereas schwannomas often presented with a palpable mass as their only initial symptom. Patients with solitary neurofibromas were significantly older, often female, and more likely to have tumor on the right side than patients with schwannomas, malignant neural sheath tumors, or neurofibromas associated with VRD. Solitary neurofibromas could often be totally resected without added deficit by sacrificing fascicles entering and leaving tumor that were determined to be “nonfunctional” by intraoperative nerve action potential recordings. Resection of neurofibromas associated with VRD sometimes but not always resulted in significant loss. Operation is nonetheless recommended, especially when malignancy is suspected because of rapidly increasing size, when severe pain or neural deficit is present, or when compression of adjacent plexus elements is a concern. Schwannomas and benign non-neural sheath tumors can usually be extirpated without damage to plexus elements. Forequarter amputation is advised for malignant intrinsic tumors involving distal plexus elements even though gross total resection seems feasible.

A rare case of epithelioid sarcoma was presented. To our knowledge this is the 25th case reported in Japan.A 36-year-old man was admitted to our hospital complaining of diffuse swelling with pain in the right upper arm. Although at 30 years of age the patient had been aware of painless nodule about 1.0cm in diameter on his right forearm, he hadn't sought medical advice for 5 years. At 35 years he underwent wide excision of the tumor in other hospital, but local recurrence was found 6 months after the operation. He had eventually agreed to reoperation, but died of metastatic pleural effusion 11 months after forequarter amputation.

Forequarter or interscapulothoracic amputation is a major surgical procedure indicated primarily in the treatment of malignant lesions involving the bony and soft tissue parieties of the upper part of the arm, shoulder, and scapula. It is also indicated in extensive trauma with irreparable damage to the shoulder area and as a palliative measure in intractable pain caused by incurable tumors of the shoulder girdle. Several operative techniques have been described: the classical Berger approach, an anterior pectoral approach, and posterior retroscapular approaches. A radical transthoracic approach has been described in cases in which the tumor had spread through the chest wall. The two main goals of these approaches have been early ligation of the subclavian vessels and immediate exploration for operability. This report details our experience with a modified technique for radical forequarter amputation and chest wall resection in which a transmediastinal approach is employed. This approach was used in two patients: One had a radiation-induced fibrosarcoma of the left axilla and adjacent chest wall following a radical mastectomy 19 years earlier, and the other patient had a recurrent rhabdomyosarcoma of the right axilla with invasion of the chest wall. This technique avoids time-consuming and individual excision of ribs and minimizes the amount of blood loss by early ligation of the internal mammary vessels. Safe and excellent exposure and division of the subclavian vessels and early exploration for mediastinal and intrathoracic involvement are made possible. Details of the procedure with illustrations are described.

Sixteen patients are presented who had sarcomas of the chest wall at a site where a prior malignancy had been irradiated. The first malignancies included breast cancer (ten cases), Hodgkin's disease (four cases), and others (two cases). Radiation doses varied from 4200 to 5500 R (mean, 4900 R). The latency period ranged from 5 to 28 years (mean, 13 years). The histologic types of the radiation-induced sarcomas were as follows: malignant fibrous histiocytoma, nine cases; osteosarcoma, six cases; and malignant mesenchymoma, one case. The only long-term survivor is alive and well 12 years after resection of a clavicular chondroblastic osteosarcoma. Three cases were recently diagnosed. Despite aggressive multimodality treatment, the remaining 13 patients have all died from their sarcomas (mean survival, 13.5 months). All patients have apparently been cured of their first malignancies. Chemotherapy was ineffective. No treatment, including forequarter amputation, appeared to palliate the patients with supraclavicular soft tissue sarcomas. Major chest wall resection offered good palliation for seven of eight patients with sarcomas arising in the sternum or lateral chest wall. Close follow-up is needed to detect signs of these sarcomas in the ever-increasing number of patients receiving therapeutic irradiation.

The patient was a 65-year-old man suffering from enchondromatosis; the lesions were distributed in a bilateral manner and involved the left scapula, humerus, fourth and fifth phalanges, the right femur, tibia and so on. At the age of sixty-five he began to have pain and swelling in the left shoulder. It had rapidly increased in swelling. Clinical examination revealed reddened tumor (10x8x4xcm). Rentgenologic examination demonstrated a expansive bone distruction and irregular calcified focus in the left acromion. Angiogram showed malignancy. We performed a forequarter amputation since no metastasis was found elsewhere. Microscopic examination showed chondrosarcomatous and fibrosarcomatous components.

Four patients with sarcoma arising in bone following therapeutic irradiation for breast carcinoma are presented, along with a review of the 40 patients who have been previously reported in the literature. The majority of these lesions arose in the scapula and the most frequently reported histology is osteosarcoma. The incidence of these lesions has been reported as 0.05% to 0.23% in three previous series. The average latent period between irradiation and the diagnosis of the sarcoma is 10.9 years with a range of 4.5-24 years. The average survival following diagnosis in this series was 2.4 months, which is comparable to other series. However, one patient treated by forequarter amputation and another treated by chemotherapy and radiotherapy survived 4 and 3 years, respectively.

1. Resection of the shoulder for a malignant tumour involving the scapula which was too extensive for treatment by excision of the bone is described. 2. The procedure is suggested as an alternative to forequarter amputation in suitable instances.

This analysis of major exarticulations performed for malignant disease of the extremities encountered at the Mayo Clinic indicates that the survival rates were adversely affected by the patients who received surgical treatment as a palliative measure. Conversely, some patients regarded as having a very dismal prognosis have had a surprisingly long postoperative survival. It can only be conjectured at the present time that the protracted survival of patients in whom cancer cells were known to have been left in the body at the time of operation may be attributable in part to the patient's own resistance to cancerous invasion. Gordon-Taylor has suggested that a tumor may have the metabolic balance turned against it by some metabolic alteration of the parent organism and may cease growing for a variable time and even become smaller, only to assume its proliferative activity again at a later period. This seems a logical hypothesis. Major exarticulation is now acceptable treatment for many types of malignant disease of the extremities. Except for palliative operations, forequarter amputation is now preferred by many to shoulder-joint disarticulation for the treatment of malignant disease of the upper part of the arm. In many cases, these procedures offer the patient the only existing chance of survival. The five-year survival rates were respectively 40.6 per cent for forequarter amputation, 41.5 per cent for hindquarter amputation, 39.6 per cent for hip-joint disarticulation, and 19.2 per cent for shoulder-joint disarticulation. The survival rate for these operations as a combined group was 36.8 per cent.

A large chondroblastoma of the scapula, with articular and soft-tissue extension, the fourth recorded in this location, was removed by forequarter amputation in a 29-year-old man after 12 years of growth. Ultrastructurally, die typical chondroblastoma cells was characterized by indented, multilobular nuclei with narrow peripheral bands of electron-dense substance, by a subdivision of the cytoplasm into an electron-dense endoplasm containing most of the organelles and an electron-lucent ectoplasm largely devoid of structured components, by fine intracytoplasmic fibrils frequently forming dense band-like aggregates between endo-and ectoplasm, and by numerous blunt microvilli at the cell surface. Also present were fusiform cells of uncertain nature and multinudeated giant cells of foreign body or osteoclastic type. The interstitium contained collagen and thin reticular fibrils; the latter appeared to be a product of the tumor cells. The observed ulaastructural features support the view that chondroblastoma is a tumor derived from cartilage-forming matrix cells.

Summary Six cases of rhabdomyosarcoma of striated muscle origin (soft tissue origin) in preadolescent children are reported and the literature reviewed. Three of the patients died in 2 months, 3 months, and 3 years, respectively, following clinically manifest disease. One patient, treated by forequarter amputation, is living, well, and clinically free of disease 2 1/2 years following the first clinical manifestation. Two other patients, treated by radical operation, are also living, well, and free of disease 5 and 6 months postoperatively. Rhabdomyosarcoma of striated muscle origin continues to be a rare and catastrophic disease of childhood. Early detection with immediate application of therapy is considered to be the only hope of preventing metastases and obtaining a cure. Biopsy is thought to be the most important single aid to early recognition. As with most types of cancer, close cooperation among the surgeon, the pediatrician, and the pathologist concerned with the diagnosis and treatment of the disease is necessary. The accepted therapy is radical operation with removal of a large block of surrounding uninvolved tissues and amputation of the total part where possible and clinically deemed necessary. Roentgen therapy may be tried as a palliative measure in surgically inaccessible tumors, or in the metastases from previously excised primary neoplasms.

From 1945 to 1959, thirty-four patients with malignant tumor of the extremities were treated by exarticulation at the University of Michigan Medical Center. Two of these patients were so treated to palliate painful metastatic lesions. In three others, all of whom were treated by hemipelvectomy, incomplete removal of the tumor at the time of surgery was recognized. Of the thirty-two patients treated for primary malignant tumors in the extremities, fourteen are still alive. Of ten patients who had disarticulation of the hip, only one has survived longer than five years; another still survives, at the time of writing, two and one-half years after operation. Of the sixteen patients undergoing hemipelvectomy, four have survived more than five years; three more, who were operated on less than five years ago, are alive at the time of writing. Of eight patients who had forequarter amputation, three have survived longer than five years, and three more are still alive less than five years after operation.

Summary Although Paget's disease of bone is very common in the general population of New South Wales, sarcoma arising in bone affected by osteitis deformans is very rare and is considered to be less than 1 per cent. Twenty-nine cases of sarcoma of this type were found in the records of the four teaching hospitals in Sydney during the last ten years. Included in this series are 5 personal cases which are reported in more detail. The commonest site of the primary malignant lesion was in the shoulder girdle (9 cases), a part of the skeleton not usually affected by Paget's disease in its early stages. Another striking feature was the development of multiple sarcomatous changes in bone and in six cases in this series these were noted in the skull. Although several patients developed sarcoma after a definite history of injury and some were associated with fractures when first noted, it was not considered that there was sufficient evidence to indicate the effect of trauma in determining a malignant change. It was noted that only one case of sarcoma developed after a subtrochanteric fracture, the commonest site for fractures in patients with Paget's disease, and no case developed after surgical intervention. In most cases where a biopsy or autopsy was made the tumour was described as an osteogenic sarcoma, but cases of fibrosarcoma and chondrosarcoma were also found in this series. Amputation of the lower limb was carried out in 7 patients and one forequarter amputation was performed. Only one of these patients lived more than a year after operation. Deep X-ray was given in 16 cases, but appeared to have no effect and most patients died within a few months. There were two exceptions: a man of 56 years with a sclerosing osteogenic sarcoma of the upper end of the humerus lived three years and eight months, and a woman of 60 years with X-ray evidence of a pathological fracture and a soft tissue tumour lived seven and a half years.

Forequarter amputation combined with chest wall resection may present a difficult closure problem. In a recent case, the defect was satisfactorily closed with a free flap from the amputated extremity, employing the entire soft tissue of the forearm.

Traumatic forequarter amputation is rare and extremely mutilating. A 21-year-old male factory worker who sustained a traumatic shoulder girdle amputation is described. The injury mechanism was traction from the machine's force combined with the compressive force on the sternoclavicular joint. The factors leading to survival from this injury include rapid transportation, prompt and effective resuscitation, including treatment of shock, and adequate surgical management. Recognition of the complications associated with retrosternoclavicular dislocation is emphasized.

Angiosarcoma is a malignant tumor of vascular origin. Malignant primary vein tumors are rare. The case of a 64-year-old patient who underwent a left forequarter amputation for angiosarcoma arising from the left axillary vein, a site not previously described, is presented. Also, the literature is reviewed.

We reported a patient with a huge chondrosarcoma of the scapula combined with a large lung abscess.The patient was a 61-year-old man who had resection of the left lobe 34 years before under a diagnosis of tuberculosis.He had also pitting edema of the left upper arm.P-A view of his chest X-P showed a large mass at the left scapula region and another mass at the left lower lung region.The left lower region mass was not diagnosed before operation by surgeons and anesthesiologists. After forequarter amputation, a biopsy was performed for the mass of left lung and showed a large lung abscess with 1000ml of cold pus.

Scapulothoracic (ST) dissociation is a closed complete traumatic forequarter amputation manifested by a flail pulseless arm and well-defined roentgenographic findings. These roentgenographic findings were previously reported to be lateral displacement of the scapula and either acromioclavicular separation (17) or displaced clavicular fracture (20). In this paper we present four patients with ST dissociation who had a previously unreported combination of roentgenographic findings: lateral displacement of the scapula and sternoclavicular separation. Polytrauma was present in all previously reported cases of patients with ST dissociation. We present one patient, however, in whom ST dissociation is an isolated finding. A review of the literature, and a review of treatment options that includes some combination of amputation, shoulder arthrodesis, prosthetic fitting, and reconstructive tendon transfers, are presented.

Forequarter amputation with resection of the chest wall is indicated for primary bony and soft tissue tumors involving the shoulder girdle, axilla, and chest wall, as well as for recurrent breast cancer in the axilla after irradiation. We describe a modification of this procedure that includes an initial thoracotomy for intraoperative staging and a median sternotomy, which avoids individual division of the anterior ribs and clavicle.

In a 10-year period 35 patients underwent a proximal amputation of the upper limb because of a malignant tumor. in 27 patients a forequarter amputation was made, in one a humeroscapular disarticulation and in seven an amputation through the humerus. the observed 5-year survival was 23 per cent. Twelve out of 23 patients followed for at least 3 years also survived 3 years. Fifteen living patients were questioned concerning prosthetic use and social and psychologic factors. Only three patients used a functional (mechanical) prosthesis and only five used a cosmetic prosthesis. the other seven patients rejected the use of a prosthesis. Half of the patients had the same occupation postoperatively as preoperatively. Activities of daily living did not constitute any major problem. One of three housekeepers needed daily help. One patient seemed to have suffered obvious psychologic damage.

Five cases in which soft tissue expanders have been used as an aid to reconstruction in the upper limb are reported. The cases involved the reconstruction of the shoulder mound after forequarter amputation, excision of a large tattoo of the forearm, excision of a malignant melanoma of the elbow, excision of a giant hairy nevus of the forearm, and the creation of large advancement flaps to release an axillary burn scar contracture. No complications were noted with the use of these expanders. Patient tolerance was excellent, and the final result was significantly enhanced by the use of this technique.

From 1975 to 1982, 101 children were treated for osteogenic sarcoma at the Children's Hospital of the Medical Center and Dana Farber Cancer Institute, Boston. 12 of these patients presented proximal humerus localisation and 8 underwent a local en-bloc resection. In the past these lesions were surgically treated by disarticulation of the shoulder or by interscapulothoracic amputation (forequarter amputation); the death rate was very high. Nowadays, high-dosage chemotherapy and resection of lung metastases carry new hopes for better and prolonged survival, and also for a higher rate of complete remissions. The quality of this prolonged life can be improved if en-bloc resection of the shoulder with upper limb preservation is performed.

In the earlier part of the century, surgical efforts focused mainly on the feasibility and safety of the various surgical operations necessary for wide extirpation of soft tissue sarcoma. Major advances were made in the design and safe execution of these complex surgical procedures, such as forequarter amputation and hemipelvectomy. Functional preservation was at that time a secondary goal. In 1953, Bowden and Booher (1) proposed that carefully selected tumors could be treated by en bloc muscle group resection as an alternative to amputation with equally good local tumor control. Local recurrenceswere nevertheless very common with limb-sparing resections in the 1950’s and 1960’s. Fine et al. (2) reviewed the results of surgical treatment of soft tissue sarcomas up to the late 1960’s and noted local recurrence rates of over 50% in various reports, and in some instances up to 90%. Such local failure rates were obviously unacceptable. Surgeons soon recognized the limitations of surgery as an ablative technique in this setting, and sought the additional use of other methods based on entirely different therapeutic principles.

Scapulothoracic dissociation represents a closed traumatic forequarter amputation associated with major neurovascular injury. Radiographic findings consist of lateral displacement of the scapula on a well-centered plain film of the chest. Associated abnormalities include disruption of the acromioclavicular joint or, as in our two cases, distracted fractures of the clavicle. Persons in whom scalpulothoracic dissociation is diagnosed should undergo emergency angiography and surgery.

Traumatic forequarter amputation is a rare and devastating injury in which the arm, scapula, clavicle, and pectoral muscles are avulsed from the body by a tremendous force. The case of a man who survived this injury is presented. Replantation at this level has not been successful: treatment recommended consists of control of hemorrhage, wound debridement, ligation of vessels and nerves, coverage of their exposed stumps with muscle, unless excess contamination is present; electrical or cosmetic prostheses can be fitted later.

Sixty patients with recurrent melanoma of an extremity were treated by major amputation. Twelve patients (21%) were free of disease an average of 13 years later. This included two patients who had forequarter amputation and two others who had hemipelvectomy. Eight of the survivors underwent hip disarticulation. There were three postoperative deaths: one from pulmonary embolism, one from splenic rupture because of metastatic melanoma, and one from sepsis. In retrospect, five of the 12 survivors might have been suitable candidates for a preliminary trial of regional perfusion with chemotherapeutic agents. Amputation appears to be indicated when recurrent disease is extensive or when regional perfusion or other conservative measures have failed. It is encouraging that one out of five such desperately ill patients can still be salvaged by this approach.

An amputation neuroma is a nerve's attempt at repair following amputation. While many are asymptomatic, some present as a painful mass. We describe a patient who, following a forequarter amputation for sarcoma, developed a stump neuroma that was unusual because it was first discovered on a routine chest roentgenogram.

Forequarter amputation may seem the only surgical option when a tumour of the scapula or its overlying soft tissues invades the bones of the shoulder joint. As illustrated in this case of giant basal cell carcinoma, shoulder girdle (Tikhor-Linberg) resection is occasionally, possible, thus preserving a functional arm.