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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Targeted muscle reinnervation after upper-extremity amputation has demonstrated improved outcomes with myoelectric prosthesis function and postoperative neuropathic pain. This technique has been established in the setting of shoulder disarticulation as well as transhumeral and transradial amputations, but a detailed technique of targeted muscle reinnervation with free tissue transfer from the volar forearm after forequarter amputation has not yet been described. Here, we describe a technique using a volar forearm filet flap to achieve simultaneously satisfactory soft tissue coverage after resection of a tumor from the chest wall and targeted muscle reinnervation of the brachial plexus.

Background: 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. Methods: 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. Results: 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. Conclusion: 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. [ABSTRACT FROM AUTHOR]

Forequarter amputation is a very demolitive surgical procedure that affects the quality of life and it is performed when the tumour involves the proximal end of homerus and the shoulder. We describe here the case of a female patient with a recurrent dedifferentiated liposarcoma of the upper limb already treated with tumour asportation, isolated limb perfusion and upper limb amputation through the shoulder, who returned to our attention for a recurrence of the sarcoma in the stump. We then performed a forequarter amputation in a previous amputated limb. Since the patient underwent numerous surgical procedures, our last surgical approach was a quite challenging one. To our knowledge, it is the first described case of an interscapular-thoracic disarticulation after a previous amputation to the shoulder.

A 78-year-old woman with a history of breast cancer, melanoma, and radiation therapy presented with worsening chronic osteomyelitis and radiation necrosis of her clavicle, scapula, and upper ribs. Despite treatment with vancomycin, she experienced significant lymphedema and near-total loss of motor function in the left upper extremity. Given the progression of the disease and diminished functionality of the limb, a forequarter amputation was determined to be the only viable option beyond supportive care. The forequarter amputation was successful, and it involved the removal of the left clavicle, scapula, ribs 1-4, and the upper extremity. Within a month, the patient regained independence in all activities of daily living, highlighting the potential for improved quality of life from surgical interventions under certain circumstances. Our case serves as a reminder that the utility of the forequarter amputation extends beyond its most common uses, such as trauma or sarcoma, and in rare cases can be an option for refractory osteomyelitis of the proximal upper extremity and chest wall., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Petrovic et al.)

• Forequarter amputation is still used in orthopedic oncology as a treatment of last resort. • "Whoops" fixation refers to fracture fixation without investigating possible underlying conditions. • Oncological scenario must be ruled out in fractures preceded by trivial trauma. • Publishing such cases can participate in increasing the awareness of such cases and how to properly manage them. Even with the advancement of limb salvage surgery techniques, forequarter amputation (FQA) is still used in orthopedic oncology. Even though it might pose catastrophic sequelae on the patient's lifestyle, debilitating one's ability to perform regular tasks, FQA is still considered as a treatment of last resort for huge fungating tumors of the upper extremity. We present a case of an 18-year-old male patient, who was diagnosed in Libya with left proximal humerus fracture after a trivial trauma and underwent open reduction and internal fixation using k-wires as it was thought to be a simple fracture. Soon after, pain and swelling progressed severely and an open biopsy confirmed a diagnosis of osteosarcoma and imaging suggested metastatic disease to the lungs for which he was started on chemoradiotherapy. He was referred to our cancer center to continue his management and due to the aggressive nature of the tumor, the patient underwent palliative forequarter amputation followed by multiple lines of chemotherapy and radiotherapy, all of which failed to halt the progression of the disease. The patient was lost to follow up due to his decision to go back to Libya. "Whoops" surgeries are fixated upon repairing fractures without looking for the alarming signs on radiographs to exclude pathological entity. As in our case, the procedure done escalated the osteosarcoma into such a massive fungating tumor due to the violation of the osteosarcoma pseudo capsule, in which the only available option is to do a palliative forequarter amputation. [ABSTRACT FROM AUTHOR]

Shoulder-level amputations, including forequarter amputation and shoulder disarticulation, are very uncommon but can be incredibly devastating. Unlike other levels of upper extremity amputation, these procedures are indicated based on etiology, namely trauma, tumor, or infection. Depending on the emergent need for the procedure and if time allows, physical examination and advanced imaging modalities can be utilized for perioperative planning. Most likely, however, there will be a significant need for revision surgeries, such as targeted muscle reinnervation (TMR), following index amputation. These surgeries can dramatically improve a patient's quality of life, by allowing them to function through a myoelectric prosthesis or to enable them to live without the burden of phantom limb or neuroma pain. [ABSTRACT FROM AUTHOR]

Chondrosarcoma is the third most common primary tumour of the bone, after myeloma and osteosarcoma. Most of the chondrosarcoma grow slowly and rarely metastasize, and they have an excellent prognosis after adequate surgery. However most of them are chemo or radio-resistant. We report a case of primary chondrosarcoma of proximal humerus in a 36-year-old female who presented with a six years history of left shoulder swelling and restricted range of motion. Trucut biopsy showed a well-differentiated chondrosarcoma. The patient underwent forequarter amputation of left upper limb and was started on chemotherapy following operation.

Background and Aim: The prosthetic options for higher level amputees are limited and costly. Advancements in computer-aided design programs and three-dimensional printing offer the possibility of designing and manufacturing transitional prostheses at very low cost. The aim of this project was to describe an inexpensive three-dimensional printed mechanical shoulder prosthesis to assist a pre-selected subject in performing bi-manual activities.Technique: The main function of the body-powered, manually adjusted three-dimensional printed shoulder prosthesis is to provide a cost-effective, highly customized transitional device to individuals with congenital or acquired forequarter amputations.Discussion: After testing the prototype on a young research participant, a partial correction of the patient's spinal deviation was noted due to the counterweight of the device. The patient's family also reported improved balance and performance of some bimanual activities after 2 weeks of using the device. Limitations of the design include low grip strength and low durability. Clinical relevance The prosthetic options for higher level amputees are limited and costly. The low-cost three-dimensional printed shoulder prosthesis described in this study can be used as a transitional device in preparation for a more sophisticated shoulder prosthesis. [ABSTRACT FROM AUTHOR]

Background: Forequarter amputation (FQA) is a surgical treatment of tumors in the upper extremity and shoulder girdle that infiltrate the neurovascular bundles. In both curative and palliative settings, FQA can serve as an effective oncological treatment. Methods: This study presents the FQA-related data of 30 patients (mean age 50 years) treated between 2000 and 2012. Their medical condition was high-grade bone or soft tissue sarcoma in 26 and high-grade carcinoma in four cases. Results: Mean operation time was 119 min. One major and five minor complications occurred in the postoperative period. Resection margins were wide in 91% of patients. Local recurrence was observed in four patients after 19 months on average. Patients treated with curative intention had a 5-year survival chance of 39%. Average survival after palliative amputation was 11 months. Conclusions: FQA provides an opportunity for adequate oncological margins in large tumors, while offering relief from tumor-induced distress in palliative situations. [ABSTRACT FROM AUTHOR]

Axillary recurrence of breast cancer that involves the brachial neurovascular bundle is uncommon. However, for many patients with such recurrence, forequarter amputation can play a palliative role in relieving excruciating pain and paralysis of the upper limb. Further, for those patients who do not have distant metastasis or other local-regional recurrence, forequarter amputation provides a chance for a cure. Only a few case reports of curative amputations for recurrent breast cancer are present in the literature. Here, we report a case of forequarter amputation for curative treatment of axillary recurrent breast cancer, together with a literature review. To date, we have followed the patient for three years after amputation, during which there has been no evidence of recurrence or metastasis. Although radical resection is feasible, it can be accompanied by surgical wound complications and psychosocial stress. Therefore, an organized multidisciplinary approach is needed to ensure the success of radical resection. [ABSTRACT FROM AUTHOR]

Summary: Interscapulothoracic amputation (ISTA) encompasses the removal of the upper limb, scapula and clavicle. As the reconstructive and oncologic limb-saving techniques improved, the indications for this formidable procedure decreased. However, it is still the appropriate procedure in cases with extensive oncologic or traumatic involvement of the shoulder girdle. Following ISTA, the surgeon is not only faced with a large defect but also with severe functional and aesthetic impairments. A solution to these problems is the immediate reconstruction with a free composite transfer from the amputated extremity. We successfully treated three oncologic cases and one traumatic case using this technique. The recipient vessels included the subclavian artery and vein in three cases and the internal thoracic vessels in one case. After a mean follow-up time of 4.5 years, two of the three tumour patients were free of recurrent disease. In all cases stable wound closure was achieved. Three out of four patients would opt for surgery again, in spite of the high occurrence of complications. One patient died after a 14-year event-free postoperative course. We conclude that the defect following ISTA can be successfully covered using a free composite tissue transfer of the amputated disease-free elbow and forearm, while simultaneously reconstructing the shoulder silhouette and axilla. This procedure reduces functional and aesthetic impairments and improves the quality of life. [Copyright &y& Elsevier]

Abstract: Aims: Recurrent breast carcinoma with brachial plexus involvement is often misinterpreted as a radiation- or chemotherapy-induced brachial plexopathy. We review a case series of 4 patients at our institution within a 1-year period, and describe their diagnostic workup and treatment with a palliative periscapular amputation. Our aim is to describe this entity, indications and benefits of this procedure, when required for progressive disease, with the goal of raising a collective index of suspicion to aid in earlier diagnosis. Methods: Four patients with recurrent axillary breast cancer and symptoms consistent with a brachial plexopathy were prospectively collected over a 1-year period. A Pubmed search was conducted; pertinent articles were reviewed and reported. Results: Patients presented with intractable pain and flaccid paralysis of the ipsilateral limb. All had been previously treated with surgical resection, axillary lymph node dissection, chemotherapy, and radiation therapy. Average time from breast surgery to presentation was 78.75 months (range 11–216 months.) Workup included MRI and biopsy to confirm recurrence. Periscapular amputation was performed for each patient, all of who experienced subjective pain relief postoperatively. Three of the 4 patients are still living; one patient died of disease. Conclusion: Breast cancer survivors presenting with a brachial plexopathy should raise suspicion for recurrent disease. Close evaluation with MRI is the best first step in diagnosis. Although periscapular amputation is an aggressive surgical treatment, it is an acceptable option when disease has progressed to neurovascular involvement and a functionless limb. [Copyright &y& Elsevier]

Summary: Introduction: Locally extensive recurrent breast cancer usually portends a poor prognosis but certain cases can be treated surgically by wide soft-tissue resection as well as full-thickness chest wall resection (FTCWR). The resulting defect usually necessitates immediate flap coverage. The aim of this study was to assess local control, morbidity, choice of flap reconstruction, patient selection and overall long-term survival following surgical salvage of patients with chest wall recurrent breast cancer. Materials and methods: Forty patients were treated with wide soft-tissue resection and immediate flap reconstruction from 1984 to 2011 in a single institution. Demographic, treatment and mortality data were obtained from patients'' files. Results: Mean age at surgery was 54 years. FTCWR was performed in 19 cases including three extended forequarter amputations. Chest wall stabilisation involved a synthetic mesh in 12 patients, fascia lata in two patients, free rib grafts in one patient and synthetic mesh and free rib graft in one patient. Soft-tissue reconstruction consisted of microvascular free flaps in seven patients and pedicled flaps in 33 patients. In-hospital mortality was 0%, 30-day mortality was 5%; there were two re-operations, six minor wound complications and one pulmonary embolism. There were no flap losses. In patients operated on with curative intent (n = 31) median disease-free interval was 31 months and median survival was 52 months. Conclusions: In selected cases wide resections for extensive chest wall recurrent breast cancer can result in reasonable local control and survival. Several flap options exist for soft-tissue reconstruction. [Copyright &y& Elsevier]

Total forearm free flap procedures after forequarter amputations have been sparsely described in the literature. Using the amputated arm as a 'free filet flap' remains a viable surgical option after radical forequarter amputations performed for the resection of large, invasive tumors of the shoulder or thoracic wall region. Using the forequarter specimen as a donor site seems favorable in that it eliminates the usual donor site morbidity. Nevertheless, in our patient with invasive ductal carcinoma of the breast and a fibrosarcoma suffering from severe pain and septic conditions - which failed to respond properly to conservative therapy - as well as rapidly progressive tumor ulceration despite repeated radiation therapy, we decided to attempt complete tumor removal by hemithoracectomy as a last resort. This decision was taken following multiple interdisciplinary consultations and thorough patient information. Although technically feasible with complete tumor removal and safe soft tissue free flap coverage, the postoperative course raises questions about the advisability of such ultra radical surgical procedures, as well as about the limitations of respiratory recovery after hemithoracectomy with removal of the sternum. Hence, based on our experience with such radical tumor surgery, we discuss the issues of diminished postoperative pulmonary function, intensive care possibilities and ethical issues. The English full-text version of this article is available at SpringerLink (under 'Supplemental'). [ABSTRACT FROM AUTHOR]

Forequarter amputation is performed for high-grade malignant tumours in the proximal part of the upper extremity with palliative or curative intentions. Two cases are included in this report of patients who presented in need of urgent surgical intervention. Both patients had an actively bleeding, ulcerated or fungating mass and were haemodynamically unstable. The purpose of this report is to highlight the importance of emergency surgical intervention for such selected patients. [ABSTRACT FROM AUTHOR]

Background: Conventionally described standard techniques of forequarter amputation may not be suitable for patients presenting with neglected or maltreated very large tumors of the proximal humerus. Patients and methods: Eleven patients with unsalvageable malignant tumors of proximal humerus, who underwent forequarter amputation using a new technique between Jan 2008 to March 2010, were retrospectively analysed. This new single incision anterior approach involves supine positioning of patients, ligation of axillary vessels in the axilla followed by resection of muscles from lateral border and inferior angle of scapula, resection of lateral one-third of clavicle; resection of muscles from vertebral border and superior angle of scapula by applying superolateral traction without any incision over acromioclavicular axis or posterior scapular skin. Results: The average age was 16.27 year and minimum follow-up was 6 months (range 6-24 months). There were seven males and four females. Average duration of surgery was 62 min (range 55-90). Blood loss ranged from 400 to 750 ml. One patient had superficial infection and one patient with metastatic lesion died at 6 months follow-up. Conclusions: This technique is safe, easy, less time consuming, involves small single incision in supine position, has better wound healing and can be used for both small and large tumors of proximal humerus with or without involvement of axillary vessels. Although there was no local recurrence for last 24 months but a long term follow-up is required to comment on its actual rate. [ABSTRACT FROM AUTHOR]

Infantile myofibroma is the most common fibrous tumor of infancy, typically affecting neonates and children under 2 years of age. Though the multicentric variant portends a grave prognosis, solitary lesions have an excellent prognosis and frequently undergo spontaneous regression. Surgical excision of solitary lesions is usually curative. In this report, we describe a pediatric patient with an unusually aggressive solitary myofibroma of the axilla who ultimately required a forequarter amputation as a lifesaving measure following multiple tumor recurrences and progressive tumor growth. The clinical course, radiographic findings, histology, and management rationale are presented. [ABSTRACT FROM AUTHOR]

We are often confronted with severe cases - patients with very aggressive tumours that suppose a complex and in the same time radical approach - in our medical practice. The correct approach and management of such cases ensure both the surgical success and the patient survival. In this paper, we present the case of a young woman, who has been admitted in our clinic with a giant, irradiated tumour involving left axilla, shoulder and scapula. Due to the vast size of the tumour and to the fact that surgical biopsy revealed a poorly differentiated sarcoma; other clinics considered that the case above belongs to surgical therapy. After the clinical examination, blood tests and diagnostic imaging, which allowed the correct evaluation of the case - tumour sizes and neighbouring tissue reports - we decided to perform tumour radical excision, respectively forequarter amputation, when the patient presented a satisfactory metabolic status. The presented case supports the idea that radical excision which might involve even mutilating amputations for extensive cancers can give patients a chance, even in desperate cases. [ABSTRACT FROM AUTHOR]

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