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Forequarter Amputation
CONSTANTINE P. KARAKOUSIS, M.D., PH.D.,
F.A.C.S.
NARRATOR: JOHN L. BUTSCH, M.D., F.A.C.S.
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Forequarter Amputation
 Forequarter or Interscapulothoracic amputation
involves the removal of the upper extremity
including the scapula and most of the clavicle.
 It is performed for tumors infiltrating extensively
the brachial plexus and axillary vessels.
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Forequarter Amputation
Indications
1) Forequarter amputation is indicated for patients with
involvement of the brachial plexus and no distant
metastases after failure to or inability to apply
conservative management.
2) For patients with metastatic disease when the severity of
the symptoms in the involved arm and indolent
progression of the tumor make reasonable a palliative
application of this procedure after failure of conservative
measures.
Contraindications
When the plane of amputation can not be carried out
through grossly clean planes.
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Forequarter amputation

ANTERIOR APPROACH: The subclavian vein is divided
first, then the artery, then the trunks of plexus.

POSTERIOR APPROACH: The trunks of brachial plexus
are divided first, then the artery, then the vein.

DELTOID FASCIOCUTANEOUS FLAP: When a defect in
closure is expected.
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Figure 1
 The patient is placed in a lateral position with
the affected arm free-draped. The anterior
portion of the incision extends from the medial
end of the clavicle to the middle of this bone. It
then bifurcates, anteriorly parallel and medial to
the deltopectoral groove to the axilla, and
posteriorly over the lower neck toward the
lateral portion of the scapula. The medial
extension of the incision along the axis of the
clavicle may not be necessary if one does not
remove the middle third of the clavicle.
 The portion of the incision over the pectoralis
major and axilla is made closer to the specimen
to be, if the tumor location allows it, than the
planned division of the muscle so that the
anterior flap has a fasciocutaneous component
before the pectoralis major is divided in a more
medial position away from the neurovascular
bundle which is involved by tumor.
This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA,
1995. Reprinted with permission.
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Figure 2
 The posterior portion of the incision is
made vertically over the middle of the
scapula to its lateral border, turning in
the axilla where it meets its opposite.
Note that the skin incision is made more
lateral than the division of the muscles
(medial to the vertebral border of the
scapula) preserving thus extra viable skin
(fasciocutaneous portion of the posterior
flap).
This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP,
Copeland EM, eds), WB Saunders, Philadelphia, PA, 1995. Reprinted with permission.
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Figure 3
ANTERIOR APPROACH (Berger)1,2
 The medial portion of the clavicle is exposed after the attachments of pectoralis
major and sternocleidomastoid are divided close to this bone.
This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA,
1995. Reprinted with permission.
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 A right-angle clamp is passed around the
clavicle near the sternal end and with a
Gigli Saw the bone is divided. The same
is repeated a few centimeters laterally
and the segment of the bone is detached
from the subclavius muscle and removed.
The subclavius muscle extends from the
anterior end of the first rib to the
undersurface of the clavicle laterally
covering the subclavian vessels . A
segment of the clavicle and a smaller
section of subclavius are removed to
allow exposure and space for dissection
around the vessels when an anterior
approach is used.
Figure 4
This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA,
1995. Reprinted with permission.
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Figure 5
This figure was
published in Atlas of
Surgical Oncology
(Bland KI, Karakousis
CP, Copeland EM,
eds), WB Saunders,
Philadelphia, PA, 1995.
Reprinted with
permission.
 A right angle clamp is passed around the subclavian vein
which is ligated, suture-ligated and divided. The upper trunk
of the brachial plexus is visible.
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Figure 6
 The omohyoid muscle is divided.
The subclavian artery is divided
between vascular clamps and the
two ends are sutured with vascular
sutures and a proximal tie (not
visible). The brachial plexus trunks
are ligated with absorbable sutures
and divided. The phrenic nerve and
scalenus anterior are preserved, as
the internal jugular vein is retracted
medially (not shown).
This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA,
1995. Reprinted with permission.
10
Figure 7
This figure was
published in Atlas of
Surgical Oncology
(Bland KI, Karakousis
CP, Copeland EM,
eds), WB Saunders,
Philadelphia, PA,
1995. Reprinted with
permission.
 A flap from the posterior incision is made to the medial border of the
scapula. The trapezius muscle is divided exposing the levator scapulae,
rhomboid minor and major which are serially divided. In the inferior
part of the incision the latissimus dorsi is divided.
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Figure 8
 The dissection continues between
the serratus anterior and the chest
wall dividing the serratus close to
its origin anteriorly (2nd-9th
ribs), completing the amputation.
This figure was published in Atlas of Surgical Oncology (Bland KI, Karakousis CP, Copeland EM, eds), WB Saunders, Philadelphia, PA,
1995. Reprinted with permission.
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POSTERIOR APPROACH TO FOREQUARTER AMPUTATION
•In the original procedure (Littlewood)1,2 through a posterior incision, after
the muscles attaching the scapula to the spine and the omohyoid are
divided the trunks of the brachial plexus, the subclavian artery, and the
vein are serially divided while the skin anteriorly, the clavicle and pectoral
muscles are still intact and are divided later.
•In the modified procedure described below3 elements of both anterior and
posterior approach are combined:
•The same skin incision is used as for the anterior approach. The muscles
around the scapula posteriorly are divided; these are the trapezius, levator
scapulae, rhomboid minor and major. Superiorly the omohyoid muscle is
divided, inferiorly the latissimus dorsi.
•The pectoral muscles and clavicle are divided anteriorly.
•Through a posterior approach:
•The trunks of the brachial plexus are serially divided.
•The subclavian artery first and then the vein are ligated and
divided near the thoracic inlet, lateral to the thyrocervical trunk,
i.e. lateral to scalenus anterior.
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POSSIBLE ADVANTAGES OF THE COMBINED
POSTERIOR APPROACH
•
In patients with prior radiation and the attendant loss of tissue
planes as one dissects around the subclavian vein and artery through an
anterior approach any bleeding may be difficult to control as the anatomical
structures are tightly packed together.
•
In the combined posterior approach, with all the other tissues divided:
• Control of the neurovascular bundle can be expeditious.
•The trunks of the brachial plexus are divided first, then the subclavian artery
and then the vein. One avoids the loss of blood in the vasculature of the
specimen occurring when the vein is interrupted first.
•There is a 3cm gain in proximal margin (vessels divided lateral to scalenus
anterior as compared to the first rib.)
•Care should be exercised in a posterior approach after all the tissues around
the subclavian vessels have been divided and for the few minutes until the
subclavian vessels have been controlled that the extremity be manipulated
gently and supported to avoid undue traction on the vessels.
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Closure of the incision
The two sides of the incision are lined-up and any excess skin is trimmed.
The edges are approximated with absorbable sutures for the fascial layer. The
skin-subcutaneous fat-fascia layer of each flap extends to the edge of the
incision, while the muscle layers divided more widely can not be approximated.
The pectoral muscles, serratus anterior and latissimus dorsi constituting the
anterior, medial and lateral walls of the axilla are in contact with the
neurovascular bundle (and any tumor in this area) and can not be preserved
except for their part away from the axillary space. The trapezius muscle
although broad-based extends laterally only as a narrow strip inserting to the
acromion.
If there is not enough skin to close completely the incision, a skin graft
can be applied on the chest wall in the remaining defect. When there is a
concomitant gap in the chest wall exposing the pleural cavity, seal can be
provided through adjacent fasciocutaneous rotation flaps, covering the area(s)
from which they were moved with skin grafts; or a free flap can be transferred
with microvascular surgery for its blood supply.
Since tumors involving the brachial plexus are located medial to the
shoulder joint, the skin-subcutaneous fat over the deltoid is usually tumor-free
and can be incorporated as the deltoid fasciocutaneous flap 4 with both anterior
and posterior approaches.
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Figure 9
Deltoid Fasciocutaneous Flap
 The forequarter incision is made to circumscribe the
outline of deltoid muscle.
This figure was published in Atlas of Surgical Oncology (Bland
KI, Karakousis CP, Copeland EM, eds), WB Saunders,
Philadelphia, PA, 1995. Reprinted with permission.
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Figure 10
This figure was
published in Atlas of
Surgical Oncology
(Bland KI, Karakousis
CP, Copeland EM,
eds), WB Saunders,
Philadelphia, PA, 1995.
Reprinted with
permission.
 Posteriorly it continues along the lateral border of
the scapula toward the axilla.
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Figure 11
This figure was
published in Atlas of
Surgical Oncology
(Bland KI, Karakousis
CP, Copeland EM, eds),
WB Saunders,
Philadelphia, PA, 1995.
Reprinted with
permission.
 The fasciocutaneous flap deepens as it encounters the insertion of
trapezius and that of the muscles at the medial border of the scapula, so
that these muscles are part of the base of the flap.
 Otherwise the operation proceeds as described without the deltoid flap.
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 Deltoid flaps based at the lower neck-upper back
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 The removed specimen with exposed deltoid muscle
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 En bloc rib resection showing the chest wall defect
and collapsed left lung
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 Chest defect covered
with a deltoid flap
based on the muscles
medial to the
vertebral border of
the scapula. The
indentation in the flap
corresponds to the
chest wall defect.
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Postoperative Course and Management
 Pain management is the main issue. Phantom pain gradually
recedes with time. It is more severe and protracted in cases of
neuroma development. These can be treated with
conservative measures as well as through excision. It is
believed that the incidence of neuromas decreases if the nerve
is divided sharply under traction and allowed to retract in an
adjacent muscle. Emotional support for the advantages of the
procedure should be available5. Physical therapy,
rehabilitation and occupational therapy are needed to
strengthen the remaining arm and to teach the patient
techniques to carry out tasks normally requiring both arms.
 Consultation regarding prosthetic devices (e.g. shoulder pad
cosmetically restoring the height and roundness of the
shoulder) should be offered.
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Conclusions
 Both anterior and posterior approaches are equally
valid and tested procedures the choice depending on
the surgeon’s experience and the operative findings.
 The deltoid fasciocutaneous flap is usually free of
tumor and can provide coverage and seal of the
thoracic cavity when needed after a forequarter
amputation.
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References
1. Sim FH, Pritchard DJ, Ivins JC: Forequarter amputation. Orthop Clin
North Am 8:921-931, 1977.
2. Tooms RE: Amputations of Upper Extremity. In Canale ST (ed).
Campbell’s Operative Orthopaedics, Ed 9. St Louis, Mosby 550-560,
1998.
3. Ferrario T, Palmer P, Karakousis CP: Technique of forequarter
(interscapulo-thoracic) amputation. Clinical Orthopedics & Related
Research 423:191-195, 2004.
4. Volpe CM, Peterson S, Doerr RT, Karakousis CP: Forequarter
amputation with fasciocutaneous deltoid flap reconstruction for
malignant tumors of the upper extremity. Ann Surg Oncol 4: 298302, 1997.
5. Ducic I, Mesbahi AN, Attinger CE, Graw K: The Role of Peripheral
Nerve Surgery in the Treatment of Chronic Pain Associated with
Amputation Stumps. Hand/Peripheral Nerve, Vol 121 (3): 908-914,
2008.
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